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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: While bed rest may be required immediately after surgery, patients are typically encouraged to mobilize as soon as possible to prevent complications.
Choice B reason: Using a special soap the evening before surgery is a common preoperative instruction to reduce the risk of infection.
Choice C reason: A CPM machine is often used after hip replacement surgery to promote movement and prevent joint stiffness.
Choice D reason: A heating pad is generally not recommended on the operative site immediately after surgery due to the risk of burns and bleeding.
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The correct answer is choice B. “You will use a special soap to shower with the evening before your surgery.” Choice A rationale: Remaining in bed for at least the first 24 hours is not typically recommended. Early mobilization is encouraged to prevent complications such as blood clots and to promote faster recovery. Choice B rationale: Using a special soap to shower with the evening before surgery is a common preoperative instruction. This helps reduce the risk of infection by decreasing the number of bacteria on the skin. Choice C rationale: Continuous passive motion (CPM) machines are generally used for knee replacement surgeries, not hip replacements. They help in maintaining joint mobility and preventing stiffness, but are not standard for hip surgeries. Choice D rationale: Using a heating pad on the operative site is not recommended as it can increase swelling and the risk of burns. Cold therapy is usually preferred to reduce pain and inflammation postoperatively. |
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Correct Answer is D
Explanation
Choice A reason: Keeping the bathroom door open does not address the safety risk of the patient bearing weight on the operative foot.
Choice B reason: While it is important to assist the patient back to bed, providing a bedpan does not address the immediate safety concern.
Choice C reason: Warning the patient about restraints is not appropriate without first educating the patient about the importance of not bearing weight and the potential risks.
Choice D reason: Telling the patient to remain in the bathroom until a wheelchair can be obtained ensures the patient's safety and prevents further weight-bearing on the operative foot.
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