Postoperative Phase
Postoperative Phase ( 9 Questions)
A nurse is changing the dressing of a patient who had a chest surgery two days ago. The nurse observes that the wound edges are separated and there is a small amount of pink serous drainage on the dressing. What should the nurse do?
This is incorrect because wound dehiscence is not normal and expected at this stage of healing. Wound dehiscence is a surgical complication where an incision reopens either internally or externally. It can interfere with wound healing and pose a threat to the individual's overall health. Wound dehiscence can be partial or complete, depending on how many layers of tissue are separated. In rare cases, wound dehiscence can lead to evisceration, which is when internal organs push out through the wound.
This is correct because wound dehiscence could be a sign of dehiscence, which is a medical emergency that requires immediate attention. The nurse should call the doctor right away and monitor the patient for signs of infection, bleeding, or evisceration. The nurse should also cover the wound with a sterile dressing moistened with saline to prevent further contamination and keep the patient calm and comfortable.
This is incorrect because coughing and deep breathing can increase the abdominal pressure and worsen the wound separation. The nurse should avoid any activities that can strain the stitches or staples used to hold the wound closed while it heals. The nurse should also instruct the patient to avoid vomiting, heavy lifting, or any sudden movements that can cause further damage to the wound.
This is incorrect because applying pressure on the wound can cause more bleeding or damage to the tissues. The nurse should not touch the wound or try to close it by themselves. The nurse should only cover the wound with a sterile dressing moistened with saline and wait for the doctor's instructions. Applying pressure on the wound can also increase the risk of infection or evisceration.
Choice A reason:
This is incorrect because wound dehiscence is not normal and expected at this stage of healing. Wound dehiscence is a surgical complication where an incision reopens either internally or externally. It can interfere with wound healing and pose a threat to the individual's overall health. Wound dehiscence can be partial or complete, depending on how many layers of tissue are separated. In rare cases, wound dehiscence can lead to evisceration, which is when internal organs push out through the wound.
Choice B reason:
This is correct because wound dehiscence could be a sign of dehiscence, which is a medical emergency that requires immediate attention. The nurse should call the doctor right away and monitor the patient for signs of infection, bleeding, or evisceration. The nurse should also cover the wound with a sterile dressing moistened with saline to prevent further contamination and keep the patient calm and comfortable.
Choice C reason:
This is incorrect because coughing and deep breathing can increase the abdominal pressure and worsen the wound separation. The nurse should avoid any activities that can strain the stitches or staples used to hold the wound closed while it heals. The nurse should also instruct the patient to avoid vomiting, heavy lifting, or any sudden movements that can cause further damage to the wound.
Choice D reason:
This is incorrect because applying pressure on the wound can cause more bleeding or damage to the tissues. The nurse should not touch the wound or try to close it by themselves. The nurse should only cover the wound with a sterile dressing moistened with saline and wait for the doctor's instructions. Applying pressure on the wound can also increase the risk of infection or evisceration.