The nurse is assessing the surgical dressing of a patient who arrived on the unit an hour ago. The surgical dressing has serosanguineous drainage on the dressing. The nurse should:

change the surgical dressing immediately to prevent infection.

outline the area of drainage with a pen and mark it with the date and time.

make a note of the drainage on the worksheet to report it at the end of shift.

reinforce the dressing with clean gauze sponges and tape.

Answer and Explanation

The Correct Answer is B

A. Change the surgical dressing immediately to prevent infection. Changing the dressing immediately is unnecessary unless there is a significant issue, such as excessive drainage or signs of infection. Minor drainage can be observed unless there's a need for further intervention.

B. Outline the area of drainage with a pen and mark it with the date and time. This is the correct action to monitor the drainage over time. By marking the area, the nurse can track whether the drainage increases, stays the same, or decreases, which helps in assessing the wound’s status and effectiveness of the surgical dressing.

C. Make a note of the drainage on the worksheet to report it at the end of shift. While documentation is important, it is essential to monitor the drainage immediately after the initial assessment rather than waiting until the end of the shift.

D. Reinforce the dressing with clean gauze sponges and tape. Reinforcing the dressing may be appropriate if drainage is increasing or if the dressing is inadequate, but marking the area first is necessary for accurate tracking.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["C","E"]

Explanation

A. Dry crust on the incision line.
Dry crust on the incision line could indicate that the wound is healing well, but it is not typically a sign of infection. Infection is more commonly associated with redness, warmth, and drainage. A dry crust does not automatically suggest infection.

B. Increased urine output.
Increased urine output is generally a sign of good hydration or adequate kidney function, not an indication of infection. Infection would more likely present with a fever or abnormal wound appearance, not increased urine output.

C. Decreased level of consciousness.
A decreased level of consciousness can be a sign of sepsis, an infection that has spread throughout the body. This is a serious indicator of possible infection, especially if it is sudden or unexplained in the postoperative period.

D. Adventitious breath sounds.
Adventitious breath sounds could be a sign of a respiratory infection or complications such as pneumonia, but they are not necessarily linked to infection at the surgical site. If the sounds are related to infection, this could be a sign of a lower respiratory tract infection.

E. Oral temperature of 38.3° C (101° F).
An oral temperature of 38.3° C (101° F) is a fever, which is a classic sign of infection. Fever is a common early sign of infection in the postoperative period and should be promptly addressed to rule out surgical site infection or other complications.

A. True B. False

Correct Answer is B

Explanation

General anesthesia involves the administration of inhaled or intravenous agents that induce unconsciousness, analgesia, and muscle relaxation. Nerve blocks (spinal, caudal, epidural, and peripheral blocks) are forms of regional anesthesia, not general anesthesia.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is assessing the surgical dressing of a patient who arrived on the unit an hour ago. The surgical dressing has serosanguineous drainage on the dressing. The nurse should:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following should the nurse recognize as a sign of possible infection in a postoperative client? (Select all that apply.)

Correct Answer is ["C","E"]

Explanation

General Anesthesia is when a nerve block such as a spinal, caudal, epidural, or peripheral block is administered.

Correct Answer is B

Explanation

While completing the preoperative checklist, a patient who is almost ready for transport to the operating room states that he does not want to remove his wedding band. The nurse should:

A postoperative patient experiences separation of the layers of his abdominal surgical wound during coughing. Separation of the layers of a surgical wound is known as

A patient scheduled for surgery has an order for a preoperative surgical skin preparation. The nurse may be required to:

To help prevent errors in the surgical procedure, the National Patient Safety Goal instituted a directive that prior to presurgical medication, each patient must:

The circulating nurse is responsible for:

A similarity of roles for the scrub person and the circulating nurse is that they both:

A patient is ready for discharge following same day surgery. The education plan for this patient includes:

In order for the anesthesiologist to accurately calculate the amount of anesthesia needed for an 82-year-old patient, the nurse should have data available on the medical record, such as: