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 A

Explanation

A. When still conscious, participate in marking the surgical site. The surgical site marking should be done with patient participation before anesthesia to confirm accuracy and prevent wrong-site surgery.

B. Have a photograph of the surgical site in the medical record. Photographs are not a standard requirement for surgical verification.

C. Have the unit nurse confirm their identity. Identity confirmation is necessary but not sufficient to prevent wrong-site surgery. Marking the site is the key step.

D. Verbally state the location of the surgical site and the expected procedure. Verbal confirmation is important but should be combined with physical marking of the site to ensure accuracy.

A. time of last meal. B. pulse rate and blood pressure. C. height and weight. D. respiratory rate and oxygen saturation.

Correct Answer is C

Explanation

A. Time of last meal: Time of the last meal is essential for preventing aspiration during anesthesia but does not help determine the exact amount of anesthesia needed.

B. Pulse rate and blood pressure: Pulse rate and blood pressure are important for assessing the patient's cardiovascular status but are not directly used to calculate the amount of anesthesia needed.

C. Height and weight: Height and weight are critical for calculating the correct dose of anesthesia, as these factors affect the distribution and metabolism of the drug.

D. Respiratory rate and oxygen saturation: Respiratory rate and oxygen saturation are important for monitoring respiratory function, but they do not provide specific data needed to calculate the amount of anesthesia.

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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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Naxlex Comprehensive Predictor Exams

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