A nurse is assessing a patient's pain level after surgery. The patient rates their pain as 8 out of 10 and says it feels like a sharp stabbing pain in the surgical site. What should the nurse say to the patient?

Choice A reason:

The client has signs of a possible infection, such as low-grade fever, foul-smelling vaginal discharge and lower abdominal tenderness. These are complications of hysterectomy that require immediate attention from the provider. The provider may order further tests, such as a wound culture or blood tests, and prescribe antibiotics or other treatments. Therefore, notifying the provider is the first action the nurse should take.

Choice B reason:

Obtaining a wound culture from the surgical site may be necessary to identify the type of infection and the appropriate antibiotic therapy. However, this is not the first action the nurse should take. The nurse should first notify the provider of the findings and follow their orders.

Choice C reason:

Administering an antibiotic as ordered may help treat the infection and reduce the risk of further complications. However, this is not the first action the nurse should take. The nurse should first notify the provider of the findings and obtain a wound culture if ordered to determine the best antibiotic for the client.

Choice D reason:

Increasing the frequency of perineal care may help prevent or reduce infection by keeping the area clean and dry. However, this is not the first action the nurse should take. The nurse should first notify the provider of the findings and administer an antibiotic as ordered to treat the infection.

Choice A reason:

This is incorrect because wound dehiscence is not normal and expected at this stage of healing. Wound dehiscence is a surgical complication where an incision reopens either internally or externally. It can interfere with wound healing and pose a threat to the individual's overall health. Wound dehiscence can be partial or complete, depending on how many layers of tissue are separated. In rare cases, wound dehiscence can lead to evisceration, which is when internal organs push out through the wound.

Choice B reason:

This is correct because wound dehiscence could be a sign of dehiscence, which is a medical emergency that requires immediate attention. The nurse should call the doctor right away and monitor the patient for signs of infection, bleeding, or evisceration. The nurse should also cover the wound with a sterile dressing moistened with saline to prevent further contamination and keep the patient calm and comfortable.

Choice C reason:

This is incorrect because coughing and deep breathing can increase the abdominal pressure and worsen the wound separation. The nurse should avoid any activities that can strain the stitches or staples used to hold the wound closed while it heals. The nurse should also instruct the patient to avoid vomiting, heavy lifting, or any sudden movements that can cause further damage to the wound.

Choice D reason:

This is incorrect because applying pressure on the wound can cause more bleeding or damage to the tissues. The nurse should not touch the wound or try to close it by themselves. The nurse should only cover the wound with a sterile dressing moistened with saline and wait for the doctor's instructions. Applying pressure on the wound can also increase the risk of infection or evisceration.