Which nursing action should the nurse implement to prevent wound dehiscence in the postoperative client?

Increase the client’s intake of Vitamin C.

Teach the client to splint the incision when coughing.

Have the client do abdominal exercises.

Perform passive range of motion exercises.

Answer and Explanation

The Correct Answer is B

Choice A Reason:

Increasing the client’s intake of Vitamin C can help with wound healing due to its role in collagen formation. However, this is not an immediate action to prevent wound dehiscence. While important for overall recovery, it does not directly address the mechanical stress on the incision site that can lead to dehiscence.

Choice B Reason:

Teaching the client to splint the incision when coughing is the most effective immediate action to prevent wound dehiscence. Splinting provides support to the incision site, reducing the risk of the wound opening due to the pressure exerted during coughing or other activities that increase intra-abdominal pressure. This method directly addresses the mechanical stress that can cause dehiscence.

Choice C Reason:

Having the client do abdominal exercises is not appropriate in the immediate postoperative period as it can increase the risk of wound dehiscence. Abdominal exercises can put additional strain on the incision site, potentially leading to separation of the wound edges.

Choice D Reason:

Performing passive range of motion exercises is beneficial for preventing complications such as joint stiffness and muscle atrophy. However, it does not specifically address the prevention of wound dehiscence. These exercises do not provide the necessary support to the incision site to prevent it from opening.

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Correct Answer is D

Explanation

Choice A reason:

Initiating droplet precautions is not sufficient for a client presenting with symptoms such as coughing up blood, productive cough, and night sweats. These symptoms are indicative of possible tuberculosis (TB), which is an airborne disease. Droplet precautions are used for infections spread through large respiratory droplets, such as influenza or pertussis, but not for TB.

Choice B reason:

Considering standard precautions to be sufficient is incorrect. Standard precautions are the basic level of infection control that should be used in the care of all patients to prevent the spread of infections. However, for a client with symptoms suggestive of TB, additional airborne precautions are necessary to prevent the spread of the disease.

Choice C reason:

Transferring the client to a positive pressure room is inappropriate. Positive pressure rooms are designed to keep contaminants out and are used for protecting immunocompromised patients from infections. For a client with suspected TB, a negative pressure room is required to prevent the spread of infectious particles to other areas.

Choice D reason:

Initiating airborne precautions is the correct intervention. Airborne precautions are necessary for diseases that are transmitted through smaller respiratory droplets that can remain suspended in the air and be inhaled by others. Tuberculosis is one such disease, and initiating airborne precautions helps to prevent the spread of the infection to healthcare workers and other patients.

Correct Answer is ["0.5"]

Explanation

Step 1: Convert the prescribed dose from mcg to mg.

235 mcg ÷ 1000 = 0.235 mg

Step 2: Determine the strength of the available tablet.

Available strength = 0.5 mg per tablet

Step 3: Calculate the number of tablets needed.

Number of tablets = 0.235 mg ÷ 0.5 mg/tablet

Step 4: Perform the division.

0.235 ÷ 0.5 = 0.47

Step 5: Round the answer to the nearest tenth.

0.47 rounded to the nearest tenth = 0.5

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Which nursing action should the nurse implement to prevent wound dehiscence in the postoperative client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a newly admitted client whose chief complaint is “coughing up blood” and whose recent history includes a productive cough and night sweats. What is the nurse’s priority intervention?

Correct Answer is D

Explanation

A nurse is caring for a client prescribed drug N 235 mcg PO daily. Available is drug N PO 0.5 mg per 1 scored tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["0.5"]

Explanation

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