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 C

Explanation

A. Emergency. Emergency surgeries are performed immediately to treat life-threatening conditions. Breast implants following a mastectomy are not an emergency, but rather a planned procedure.

B. Palliative. Palliative surgeries are performed to relieve symptoms or improve quality of life, often in terminal illness. While reconstructive surgery after a mastectomy can improve a patient's quality of life, it is not primarily palliative.

C. Reconstructive. Reconstructive surgery is performed to restore or improve the function or appearance of a body part, particularly after trauma or disease. Breast implants after a mastectomy are classified as reconstructive surgery because they aim to restore the appearance of the breast after its removal.

D. Curative. Curative surgeries are intended to remove or treat a disease to cure the patient. While breast implants can improve a patient's appearance after a mastectomy, they do not cure any underlying disease or condition.

A. lying supine with knees flexed. B. early ambulation C. turning to the left side. D. drinking fluids that are very hot.

Correct Answer is B

Explanation

A. Lying supine with knees flexed. Lying supine with knees flexed is a common position that can help relieve abdominal discomfort by relaxing the abdominal muscles and allowing gas to pass more easily.

B. Early ambulation: Early ambulation promotes the movement of gas through the intestines, which helps relieve bloating and discomfort. Moving helps stimulate peristalsis and reduces the risk of constipation or gas accumulation postoperatively.

C. Turning to the left side. Although turning to the left side may help with digestion, early ambulation is the most effective intervention for promoting the passage of gas and alleviating abdominal distention and discomfort.

D. Drinking fluids that are very hot: Hot liquids may irritate the stomach and intestines and are not a recommended strategy for relieving gas pain. Cool or room-temperature fluids are typically better tolerated postoperatively.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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