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 A
The correct answer is Choice A
Choice A rationale: Placing the patient in a supine position with knees flexed reduces tension on the abdominal wall and minimizes strain on the surgical site. This position promotes relaxation of the rectus muscles and decreases intra-abdominal pressure, which helps prevent further wound separation and evisceration. It also facilitates optimal circulation and allows for rapid assessment and intervention. Scientifically, this positioning is a first-line response to wound dehiscence and aligns with evidence-based emergency protocols.
Choice B rationale: Covering the wound with a clean towel does not meet sterile technique standards required for exposed internal tissues. In cases of dehiscence, especially with evisceration, sterile saline-soaked gauze is necessary to maintain tissue moisture and prevent infection. A clean towel may introduce contaminants and lacks the moisture-retaining properties needed to protect exposed organs. This action fails to meet scientific wound care principles and may compromise patient safety and healing.
Choice C rationale: Applying an abdominal binder to a dehisced wound can exert pressure on the compromised tissue and exacerbate separation. Binders are used prophylactically or postoperatively for support, not in acute dehiscence. Compression over an open or unstable wound risks ischemia, tissue damage, and impaired healing. Scientifically, this intervention is contraindicated during active wound separation and does not align with emergency wound management protocols.
Choice D rationale: Offering a drink of water is inappropriate during an acute surgical complication like wound dehiscence. Oral intake may be contraindicated due to potential need for surgical intervention or anesthesia. Additionally, hydration does not address the immediate risk of infection, tissue exposure, or hemorrhage. Scientifically, this action lacks relevance to the pathophysiology of dehiscence and may delay critical care. Priority should be stabilization and surgical evaluation, not fluid intake.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
Choice A reason: While opioids can lower blood pressure, it is not as common as respiratory depression.
Choice B reason: Causing drowsiness is a common side effect of opioids, but it is less critical than respiratory effects.
Choice C reason: Opioids do not typically induce a cough; they may actually suppress coughing.
Choice D reason: Opioids can slow the respiratory rate, which is a critical side effect that nurses must monitor for and educate patients about.
Correct Answer is A
Explanation
The correct answer is Choice A
Choice A rationale: Placing the patient in a supine position with knees flexed reduces tension on the abdominal wall and minimizes strain on the surgical site. This position promotes relaxation of the rectus muscles and decreases intra-abdominal pressure, which helps prevent further wound separation and evisceration. It also facilitates optimal circulation and allows for rapid assessment and intervention. Scientifically, this positioning is a first-line response to wound dehiscence and aligns with evidence-based emergency protocols.
Choice B rationale: Covering the wound with a clean towel does not meet sterile technique standards required for exposed internal tissues. In cases of dehiscence, especially with evisceration, sterile saline-soaked gauze is necessary to maintain tissue moisture and prevent infection. A clean towel may introduce contaminants and lacks the moisture-retaining properties needed to protect exposed organs. This action fails to meet scientific wound care principles and may compromise patient safety and healing.
Choice C rationale: Applying an abdominal binder to a dehisced wound can exert pressure on the compromised tissue and exacerbate separation. Binders are used prophylactically or postoperatively for support, not in acute dehiscence. Compression over an open or unstable wound risks ischemia, tissue damage, and impaired healing. Scientifically, this intervention is contraindicated during active wound separation and does not align with emergency wound management protocols.
Choice D rationale: Offering a drink of water is inappropriate during an acute surgical complication like wound dehiscence. Oral intake may be contraindicated due to potential need for surgical intervention or anesthesia. Additionally, hydration does not address the immediate risk of infection, tissue exposure, or hemorrhage. Scientifically, this action lacks relevance to the pathophysiology of dehiscence and may delay critical care. Priority should be stabilization and surgical evaluation, not fluid intake.
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