More Questions on This Topic
More Questions on This Topic ( 10 Questions)
A nurse is planning care for a client who has a surgical incision with staples. Which intervention should the nurse include in the plan to prevent wound dehiscence?
Steri-strips are thin adhesive strips that are used to approximate wound edges and enhance healing by primary intention. They are not used to prevent wound dehiscence, as they do not provide enough support for the wound closure.
Rationale: Splinting the incision when coughing or sneezing helps to reduce tension and stress on the wound edges and prevent wound dehiscence, which is the partial or total separation of the wound layers. The nurse should also instruct the client to avoid lifting heavy objects or straining during bowel movements.
Changing the dressing frequently using sterile technique helps to prevent wound infection but not wound dehiscence. The frequency of dressing changes depends on the type and amount of drainage, the condition of the wound, and the type of dressing used.
Irrigating the wound with normal saline helps to cleanse the wound and remove debris but not prevent wound dehiscence. Irrigation should be done gently and carefully to avoid disrupting granulation tissue or causing trauma to the wound.
Correct answer: B) Instruct the client to splint the incision when coughing
Rationale: Splinting the incision when coughing or sneezing helps to reduce tension and stress on the wound edges and prevent wound dehiscence, which is the partial or total separation of the wound layers. The nurse should also instruct the client to avoid lifting heavy objects or straining during bowel movements.
Incorrect options:
A) Apply steri-strips along the incision line - Steri-strips are thin adhesive strips that are used to approximate wound edges and enhance healing by primary intention. They are not used to prevent wound dehiscence, as they do not provide enough support for the wound closure.
C) Change the dressing every 8 hours using sterile technique - Changing the dressing frequently using sterile technique helps to prevent wound infection but not wound dehiscence. The frequency of dressing changes depends on the type and amount of drainage, the condition of the wound, and the type of dressing used.
D) Irrigate the wound with normal saline twice daily - Irrigating the wound with normal saline helps to cleanse the wound and remove debris but not prevent wound dehiscence. Irrigation should be done gently and carefully to avoid disrupting granulation tissue or causing trauma to the wound.