A nurse is changing the dressing of a patient who had a chest surgery two days ago. The nurse observes that the wound edges are separated and there is a small amount of pink serous drainage on the dressing. What should the nurse do?

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.

Choice A reason:

This is a correct statement by the client. Using a pillow between the legs when sleeping helps to maintain the hip in abduction and prevent dislocation of the prosthesis.

Choice B reason:

This is also a correct statement by the client. Avoiding crossing the legs or bending forward prevents excessive flexion of the hip and reduces the risk of dislocation.

Choice C reason:

This is another correct statement by the client. Reporting any signs of infection or bleeding to the doctor is important to prevent complications such as wound infection, hematoma, or sepsis.

Choice D reason:

This is an incorrect statement by the client that indicates a need for further teaching. Resuming normal activities as soon as the client feels better is not advisable, as it may cause excessive stress on the joint and lead to loosening or fracture of the prosthesis. The client should follow a gradual rehabilitation program and avoid activities that involve high impact, twisting, or lifting.

Choice E reason:

This is also an incorrect statement by the client that indicates a need for further teaching. Taking anticoagulant medication as prescribed is not enough to prevent thromboembolic events after a total hip replacement. The client should also wear compression stockings, use intermittent pneumatic compression devices, and perform ankle and foot exercises as instructed. The client should also monitor for signs of bleeding or bruising and report any abnormal findings to the doctor.