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The nurse is caring for a client with a diagnosis of a ruptured appendix who underwent an emergency exploratory laparotomy with appendectomy 48 hours ago.

The 55-year-old client was admitted through the Emergency Department (ED) with fever, chills, nausea, and diﬀuse abdominal pain. Computed tomography (CT) of the abdomen confirmed a ruptured appendix with widespread inﬂammation. The client is 6'1" (193.04 cm) tall and weighs 260 lbs (117.93 kg). The client is obese with a BMI of 31.6 kg/m2. The client underwent an immediate exploratory laparotomy with appendectomy. The wound was not closed and was packed with sterile gauze.

The client's past medical history includes gastric reﬂux disease (GERD), hypertension, and type 2 diabetes mellitus. The client has no known drug allergies (NKDA). Home medications include lisinopril 20 mg 1 tablet PO every day, omeprazole 40 mg 1 capsule PO every day, metformin ER (extended-release) 750 mg 1 tablet PO every day, and acetaminophen 325 mg 2 tablets PO every 4 hours PRN for pain.

The physician is notified of the change in the client's wound. The nurse receives orders to obtain blood cultures x 2 and a culture of the wound now. The nurse prepares to change the client’s abdominal dressing and obtain a wound culture.

Which steps are appropriate for this procedure? (Select all that apply.)

Wear sterile gloves to pack the wound.

Clean the skin around the wound with non-sterile 4x4 gauze.

Don an eye shield before irrigating the wound.

Use alcohol-based hand sanitizer between glove changes.

Pour sterile normal saline into a sterile irrigation tray.

Obtain a wound culture before the wound bed is irrigated.

Cover the irrigated packing with an ABD pad.

Assess pain prior to starting the procedure.

Wear sterile gloves to remove the old dressing.

Answer and Explanation

Correct Answer : A,C,E,F,G,I

a) It is important to wear sterile gloves when packing the wound to prevent the introduction of new bacteria into the wound.
c) Donning an eye shield protects the nurse from splash-back or aerosolized particles during irrigation.
e) Sterile normal saline should be used for irrigation to prevent introducing new bacteria to the wound. It should be poured into a sterile irrigation tray.
f) A wound culture should be obtained before the wound bed is irrigated to prevent diluting the specimen with irrigation solution.
g) After irrigating the wound and packing it with sterile gauze, the packing should be covered with an ABD pad to protect the wound and prevent contamination.
h) Assessing pain prior to starting the procedure is important to establish a baseline for pain management and to monitor the client's response to the procedure.
i) Sterile gloves should be worn when removing the old dressing to prevent introducing new bacteria to the wound.
b) Cleaning the skin around the wound with non-sterile gauze is not appropriate as it can introduce new bacteria to the wound.
d) Alcohol-based hand sanitizer is not a substitute for hand washing and should not be used between glove changes as it does not eﬀectively remove all bacteria from the hands.

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Correct Answer is ["A","B","D","E"]

Explanation

It is important to explain the procedure in detail before beginning to help the child understand what is happening and reduce anxiety. Having the child blow on a pinwheel during insertion can help distract them and reduce discomfort. A size 10 Fr catheter is appropriate for a toddler-age child ¹². Inserting 2% lidocaine lubricant into the meatus can help reduce discomfort during the procedure.

On the other hand, inserting the catheter about 5 cm may not be appropriate as the depth of insertion varies depending on the child's anatomy. Using firm pressure if resistance is met is not recommended as it can cause injury to the urethra.

A. Presence of exudate B. A number of sutures C. Approximation of edges D. Time of last antibiotic E. Color of the wound bed

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

Explanation

a. Presence of exudate: The presence and amount of exudate can indicate the severity of the infection and the eﬀectiveness of treatment.

c. Approximation of edges: This refers to how well the edges of the wound are coming together and healing, which is important in evaluating the progress of healing.

e. Color of wound bed: The color of the wound bed can also indicate the severity of infection and the eﬀectiveness of treatment.

Therefore, the correct answers are a, c, and e.

The number of sutures and the time of the last antibiotic are important information for the nurse to know, but they do not need to be included in the documentation of the wound assessment and dressing change.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse provides care to a toddler-age client and prescribed catheterization to obtain a urine specimen. Which procedure does the nurse implement? (Select all that apply)

Correct Answer is ["A","B","D","E"]

Explanation

The nurse provides care for a patient with an infected surgical wound. The nurse assesses the wound and changes the dressing. Which does the nurse include in the documentation? Select all that apply.

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

Explanation

A client recovering from surgery sits in a chair for breakfast. Which action does the nurse take before applying newly prescribed anti-embolism stockings to the client's lower extremities?

The nurse provides care for a child with an abdominal wound. The wound edges are approximated. Which does the nurse include when rendering the prescribed wound care to this child? (Select all that apply)

The nurse delegated vital signs for a group of patients to the unlicensed assistive personnel (UAP). Which client condition would prohibit having a rectal temperature taken by the UAP?

A client receives a diagnosis of right-sided paralysis. Which action does the nurse take when assisting the client in transferring from the bed to the wheelchair?

The nurse provides care for a client having an incisional biopsy of a skin lesion. Which teaching about the care of the site does the nurse provide to the client?

The nurse evaluates a client's plan of care. The client has an outcome of 'Client will learn self-glucose testing before discharge'. When evidence best allows the nurse to meet the outcome of the plan?

In which situation is the nurse determined to be negligent?