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:

Notifying the surgeon of the blood pressure is important, but it is not the first action the nurse should take. The primary concern is to manage the patient’s high blood pressure to prevent any complications during surgery. Once the blood pressure is under control, the nurse can then notify the surgeon if necessary.

Choice B Reason:

Documenting the blood pressure on the pre-op checklist is a necessary step, but it is not the immediate priority. The nurse’s first action should be to address the elevated blood pressure to ensure the patient’s safety. Documentation can be done after the immediate concern is managed.

Choice C Reason:

Having the client relax and take deep breaths can help lower blood pressure temporarily, but it is not a sufficient intervention for a blood pressure reading as high as 174/88. The nurse should take a more direct approach to manage the hypertension, such as administering the prescribed antihypertensive medication.

Choice D Reason:

Administering the antihypertensive medication is the most appropriate first action. The patient is NPO (nothing by mouth) except for medications, indicating that the medication should still be given. This action directly addresses the elevated blood pressure and helps to stabilize the patient before surgery.

Correct Answer is ["66.7"]

Explanation

Step 1: Determine the total volume to be administered. Total volume = 1600 mL

Step 2: Determine the total time in hours. Total time = 24 hours

Step 3: Calculate the rate in mL/hr. Rate = Total volume ÷ Total time Rate = 1600 mL ÷ 24 hours Rate = 66.6667 mL/hr

Step 4: Round to the nearest tenth. Rounded rate = 66.7 mL/hr

The nurse should set the IV pump to deliver 66.7 mL/hr.

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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 client who receives an antihypertensive medication daily is NPO except medications for surgery. The most recent blood pressure recording is 174/88. What action should the nurse take first?

Correct Answer is D

Explanation

The nurse must administer 1600 mL of total parenteral nutrition (TPN) over 24 hours. The nurse should set the IV pump to deliver how many mL/hr? (Round to the nearest tenth, do not use trailing zeros, use a leading zero if it applies)

Correct Answer is ["66.7"]

Explanation

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