The nurse is assessing a client six hours postoperative from abdominal surgery. The nurse notes a small amount of drainage that has been absorbed into the initial surgical dressing. What would be an appropriate response by the nurse?
Notify the surgeon immediately
Immediately change the surgical dressing
There's no action is required
Circle the drainage on the dressing site and continue to monitor
The Correct Answer is D
A. Notify the surgeon immediately: Notifying the surgeon is appropriate for large or expanding drainage or signs of hemorrhage, but a small amount initially soaked into the dressing often warrants monitoring first.
B. Immediately change the surgical dressing: Routine dressing changes are performed per protocol; changing a dressing unnecessarily can increase infection risk and disrupt the initial postoperative seal unless the dressing is soaked through or contaminated.
C. There's no action is required: Doing nothing at all ignores the need to document and monitor drainage; some action to mark and observe is appropriate.
D. Circle the drainage on the dressing site and continue to monitor: Marking the drainage boundary and documenting the time allows tracking for increases - a standard immediate response to small, stable drainage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Bronchovesicular: Bronchovesicular sounds are normal breath sounds heard over central airways and are not adventitious findings of bronchoconstriction.
B. Wheezing: Wheezes are high-pitched, musical sounds produced by airflow through narrowed airways and are commonly heard with bronchoconstriction (e.g., asthma).
C. Rales: Rales (crackles) are discontinuous sounds often associated with fluid in the alveoli (e.g., pulmonary edema, pneumonia), not bronchoconstriction.
D. Bruit: A bruit is an abnormal vascular sound heard over arteries and is unrelated to lung auscultation.
Correct Answer is B
Explanation
A. Prevention of wound infection: Pneumatic compression devices do not actively prevent surgical wound infection; infection prevention relies on aseptic technique, antibiotics as indicated, and wound care.
B. Promote circulation of venous blood: These devices intermittently compress the limbs to enhance venous return, reduce venous stasis, and lower the risk of deep vein thrombosis (DVT).
C. Improve mobility: While used when mobility is limited, the devices themselves do not restore or improve the patient’s ability to ambulate.
D. Encourage lung expansion: Lung expansion is promoted by deep-breathing exercises, incentive spirometry, and positioning; pneumatic compression devices target limb circulation rather than pulmonary mechanics.
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