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?

"Don't worry, this is normal and expected at this stage of healing.”

"I need to call your doctor right away, this could be a sign of dehiscence.”

"Can you cough and take deep breaths for me, this will help prevent infection.”

"I will apply some pressure on the wound, this will stop the bleeding."

Answer and Explanation

The Correct Answer is B

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.

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Correct Answer is B

Explanation

Choice A reason:

This is not the best response because it does not address the patient's pain experience or offer any empathy. It also implies that medication is the only option for pain relief, which may not be true.

Choice B reason:

This is the best response because it acknowledges the patient's pain and asks them to elaborate on how it affects their daily activities. This can help the nurse assess the impact of pain on the patient's quality of life and plan appropriate interventions.

Choice C reason:

This is not the best response because it focuses on the duration and triggers of pain, which are more relevant for chronic pain than acute pain. It also does not show empathy or validate the patient's pain rating.

Choice D reason:

This is not the best response because it only expresses sympathy but does not ask the patient any questions or offer any solutions. It may also sound patronizing or dismissive to some patients.

A. Administer oxygen via nasal cannula. B. Increase the rate of intravenous fluids. C. Notify the physician or surgeon. D. Administer pain medication.

Correct Answer is B

Explanation

A. Administering oxygen may help improve oxygen saturation, but the primary concern is hypotension and tachycardia, which suggest possible hypovolemia.
B. The patient’s vital signs, BP 90/60 mmHg, pulse 120 beats/min, urine output 20 mL/h, indicate early hypovolemic shock. The priority intervention is to increase intravenous fluids to restore circulating volume and perfusion.
C. Notifying the physician is important but should follow initiating immediate interventions to stabilize the patient.
D. Administering pain medication does not address the patient’s hemodynamic instability and is not a priority at this time.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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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?

A nurse is monitoring a patient's temperature after surgery. The patient has a fever of 38.5°C (101.3°F) and chills. What is the most likely cause of the fever?