Which finding will alert the nurse to a potential wound dehiscence?

A. Call the health care provider, a blockage is present in the tubing: A sudden decrease in drainage can indicate a blockage in the tubing, which could lead to fluid buildup and infection. The provider should be notified so that interventions can be taken (e.g., irrigation, assessment for clot formation).

B. Remove the drain, a drain is no longer needed: The nurse should not remove the drain without a provider’s order. A decrease in drainage does not necessarily mean the wound has healed.

C. Do nothing as long as the evacuator is compressed. Even if the evacuator is compressed, a sudden decrease in drainage is abnormal and requires further investigation. Ignoring it can lead to complications like hematoma or infection.

D. Chart the results on the intake and output flow sheet. While documenting the change is important, charting alone is not an appropriate intervention. The nurse must also assess for possible causes of the decreased drainage and notify the provider.

A. Initiate a peripheral IV: While an IV line is useful for medication administration, the patient’s pain has significantly improved with nitroglycerin. An IV may be necessary later, but it is not the next step in this scenario.

B. Administer another nitroglycerin tablet: Nitroglycerin can be repeated every 5 minutes up to 3 doses if chest pain persists or does not decrease significantly. Since the pain has improved (from 6 to 2), additional nitroglycerin is unnecessary.

C. Obtain an ECG/EKG: Even though the pain improved, unstable angina can progress to myocardial infarction. An ECG helps evaluate for ischemic changes and ensures the pain is truly resolving.

D. Call the Rapid Response Team (RRT): RRT should be called for worsening chest pain, unresponsiveness, or hemodynamic instability. Since the pain has improved, calling RRT is unnecessary.