Which action is essential when assessing for drainage in a client with a large abdominal wound?

Feel the top of the client’s legs.

Examine area underneath the client.

Ask the client to cough forcefully.

Have the client sit up and lean forward.

Answer and Explanation

The Correct Answer is B

This is essential because drainage from a large abdominal wound may collect under the client and be missed if only the dressing is inspected. The amount, color, and consistency of drainage should be documented and reported to the health care provider.

Choice A is wrong because feeling the top of the client’s legs will not help assess for drainage in a large abdominal wound.

Choice C is wrong because asking the client to cough forcefully may increase the risk of dehiscence (separation of wound edges) or evisceration (protrusion of internal organs through the wound) in a large abdominal wound.

Choice D is wrong because having the client sit up and lean forward may also increase the risk of dehiscence or evisceration in a large abdominal wound.

Normal ranges for wound drainage depend on the type, location, and size of the wound, as well as the stage of healing. Generally, drainage should decrease over time and change from bloody to serous.

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Correct Answer is C

Explanation

The client received a dose of clopidogrel at 2200. Clopidogrel is an antiplatelet drug that increases the risk of bleeding during and after a liver biopsy. The healthcare provider should be informed of this medication and decide whether to postpone the biopsy or administer reversal agents.

Choice A is wrong because being NPO since 2300 is a standard preparation for a liver biopsy.

Choice B is wrong because pain in the left lower quadrant and constipation are not related to the liver biopsy and do not pose an immediate risk.

Choice D is wrong because having an allergy is not relevant to the liver biopsy unless it is an allergy to the local anesthetic or contrast agent used.

A. Apply warm soaks to reduce the inflammation. B. Notify the health care provider immediately of the infection. C. Place the client on contact (wound) precautions. D. Document the findings and continue to monitor the wound.

Correct Answer is D

Explanation

. Document the findings and continue to monitor the wound. This is because a 2-day-old wound that has a crust along the edges, is red and appears slightly swollen is likely in the inflammatory phase of wound healing. This phase is characterized by hemostasis, chemotaxis, and increased vascular permeability, which can

cause redness and swelling. The crust along the edges is formed by the clotting of blood and platelets.

These are normal signs of wound healing and do not indicate infection or complications.

Choice A is wrong because applying warm soaks to reduce inflammation can interfere with the natural process of wound healing and increase the risk of infection.

Choice B is wrong because notifying the health care provider immediately of the infection is not necessary unless there are other signs of infection such as fever, pus, foul odor, or increased pain.

Choice C is wrong because placing the client on contact (wound) precautions is not required for a 2-day-old wound that is not infected or draining. Wound precautions are only indicated for wounds that are colonized or infected by multidrug-resistant organisms.

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Which action is essential when assessing for drainage in a client with a large abdominal wound?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A night nurse is preparing a client for a liver biopsy the next morning at 8:00 AM. Which data is the most important for the nurse to report to the healthcare provider? The client:.

Correct Answer is C

Explanation

Which action should the nurse take after assessing a 2-day-old wound that has a crust along the edges, is red and appears slightly swollen?

Correct Answer is D

Explanation

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