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.

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Correct Answer is D

Explanation

A. Palpable peripheral pulses. Palpable pulses are important for circulatory assessment but are not relevant in determining whether the patient can eat after surgery.

B. Clear lung sounds. Clear lung sounds are important for respiratory status, but they are not the primary factor in determining whether a patient can start clear liquids.

C. Adequate urinary drainage. Urinary drainage is important for monitoring kidney function postoperatively but is not a primary factor in whether a patient can eat clear liquids.

D. Bowel sounds in all quadrants. The presence of bowel sounds indicates that the gastrointestinal system is functioning well enough to begin processing liquids, making this an important assessment before offering fluids or food.

A. dehiscence B. laceration C. evisceration D. autologous

Correct Answer is A

Explanation

A. Dehiscence: Dehiscence refers to the partial or total separation of the wound's layers, often occurring after surgery, such as when coughing increases intra-abdominal pressure.

B. Laceration: A laceration refers to a tear or break in the skin due to trauma, not a surgical complication.

C. Evisceration: Evisceration occurs when the internal organs protrude through the wound, which is a more severe complication than dehiscence.

D. Autologous: Autologous refers to using a person's own tissues or cells (e.g., blood transfusion), not a wound complication.

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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:

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