A nurse is caring for a patient who has wound dehiscence one week postoperative. Which of the following actions should the nurse take?
Place the patient supine with the knees flexed.
Cover the patient's wound with a clean towel.
Apply an abdominal binder for support.
Offer the patient a drink of water.
The Correct Answer is B
Choice A reason: Placing the patient supine with the knees flexed may be done to reduce tension on the abdominal area, but it is not the immediate action for wound dehiscence.
Choice B reason: Covering the wound with a clean towel is a priority to protect the wound from infection and further injury until it can be assessed and treated by a healthcare provider.
Choice C reason: Applying an abdominal binder may provide support to the abdominal area, but it should not be done without assessing the wound first.
Choice D reason: Offering a drink of water is not related to the immediate care of wound dehiscence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Serosanguineous drainage is a mixture of blood and clear fluid, not typically yellow and thick.
Choice B reason: Serous drainage is clear and watery, not yellow and thick.
Choice C reason: Purulent drainage is typically yellow and thick, indicating the presence of pus, which can be a sign of infection.
Choice D reason: Sanguineous drainage is fresh bleeding, bright red in color, not yellow and thick.
Correct Answer is ["A","B","C"]
Explanation
Choice A reason: Trousseau's sign is indicative of hypocalcemia and is elicited by inflating a blood pressure cuff on the arm.
Choice B reason: Carpopedal spasm is a muscular spasm involving the hands and feet that can occur with hypocalcemia.
Choice C reason: Chvostek's sign is a facial twitching that occurs when tapping on the facial nerve in front of the ear, which can be a sign of hypocalcemia.
Choice D reason: Korsakoff's psychosis is associated with chronic alcoholism and thiamine deficiency, not directly with hypocalcemia.
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