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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
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.
Correct Answer is B
Explanation
A. Nausea and vomiting. Nausea and vomiting can occur after surgery due to anesthesia and other factors. However, it is more common in patients of all ages who undergo certain types of surgery. Though these groups may be more susceptible, this is not the most specific risk.
B. Delayed healing. Both very young and older adult patients are at higher risk for delayed healing. In the very young, the immune system and cell regeneration processes are still developing, while in older adults, decreased circulation, chronic conditions, and slower cellular regeneration can impair wound healing.
C. Anorexia. Anorexia is not specific to surgical patients. While appetite loss can occur postoperatively, it is not as universally problematic in young or older surgical patients as delayed healing.
D. Hydration issues. Hydration issues can occur in all patients, especially following surgery, but they are particularly critical for the very young (due to smaller body mass and high fluid turnover) and the elderly (due to decreased kidney function and total body water). However, this is not as universally prevalent as delayed healing.
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