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°Questions°1.ID: 8482572285A client who has undergone abdominal surgery calls the nurse and reports that she just felt “something give way” in the abdominal incision. The nurse checks the incision and notes the presence of wound dehiscence. The nurse immediately: Contacts the physicianDocuments the findingsPlaces the client in a supine position with the legs flatCovers the abdominal wound with a sterile dressing moistened with sterile saline solution Correct°Rationale:Wound dehiscence is the disruption of a surgical incision or wound. When dehiscence occurs, the nurse immediately places the client in a low Fowler’s position or supine with the knees bent and instructs the client to lie quietly. These actions will minimize protrusion of the underlying tissues. The nurse then covers the wound with a sterile dressing moistened with sterile saline. The physician is notified, and the nurse documents the occurrence and the nursing actions that were implemented in response.°°Test-Taking Strategy:Use the process of elimination and note the strategic word “immediately.” Visualize this occurrence and recall that the primary concern when wound dehiscence occurs is the protrusion of underlying tissues. This will direct you to the correct option. Review the nursing actions to be taken immediately in the event of wound dehiscence if you had difficulty with this question.°°Level of Cognitive Ability:Applying°°Client Needs:Physiological Integrity °°Integrated Process:Nursing Process/Implementation°°Content Area:Perioperative Care°°Reference:Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care(6th ed., pp. 291, 292, 296). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. °2.ID: 8482572275A client who just returned from the recovery room after a tonsillectomy and adenoidectomy is restless and her pulse rate is increased. As the nurse continues the assessment, the client begins to vomit a copious amount of bright-red blood. The immediate nursing action is to: Notify the surgeon CorrectContinue the assessmentCheck the client’s blood pressureObtain a flashlight, gauze, and a curved hemostat°Rationale:Hemorrhage is a potential complication after tonsillectomy and adenoidectomy. If the client vomits a large amount of bright-red blood or the pulse rate increases and the patient is restless, the nurse must notify the surgeon immediately. The nurse should obtain a light, mirror, gauze, curved hemostat, and waste basin to facilitate examination of the surgical site. The nurse should also gather additional assessment data, but the surgeon must be
contacted immediately.°°Test-Taking Strategy:Focus on the data in the question. Noting the words “bright-red blood” will assist in directing you to the correct option. Remember that the presence of bright-red blood indicates active bleeding. Review the nursing actions to be taken immediately