Saunders Comprehensive Review for the NCLEX-RN Exam Pre-op, Intra-op, postop correctly answered 2022 (Complete And Verified Study material) (11pages) LEARNEXAMS

A nurse assesses a client's surgical incision for signs of infection. Which finding by the

nurse would be interpreted as a normal finding at the surgical site?

1. Red, hard skin

2. Serous drainage

3. Purulent drainage

4. Warm, tender skin - correct answer 2. Serous drainage

Rationale: Serous drainage is an expected finding at a surgical site. The other options

indicate signs of wound infection. Signs and symptoms of infection include warm, red,

and tender skin around the incision. Wound infection usually appears 3 to 6 days after

surgery. The client also may have a fever and chills. Purulent material may exit from

drains or from separated wound edges. Infection may be caused by poor aseptic

technique or a contaminated wound before surgical exploration; existing client

conditions such as diabetes mellitus or immunocompromise may place the client at risk.

Test-taking strategy: Use the process of elimination, noting the strategy words normal

finding. Recalling the signs of a wound infection and noting these strategy words will

direct you to option 2. Review the signs of a wound infection if you had difficulty with this

question.

When performing a surgical dressing change of a client's abdominal dressing, a nurse

notes an increase in the amount of drainage and separation of the incision line. The

underlying tissue is visible to the nurse. The nurse should do which of the following in

the initial care of this wound?

1. Leave the incision open to the air to dry the area.

2. Irrigate the wound and apply a sterile dry dressing.

3. Apply a sterile dressing soaked with normal saline.

4. Apply a sterile dressing soaked in providone-iodine (Betadine). - correct answer 3.

Apply a sterile dressing soaked with normal saline.

Rationale: Wound dehiscence is the separation of wound edges at the suture line. Signs

and symptoms include increased drainage and the appearance of underlying tissues.

Dehiscence usually occurs 6 to 8 days after surgery. The client should be instructed to

remain quiet and avoid coughing or straining. The client should be positioned to prevent

further stress on the wound (semi-Fowler's). Sterile dressings soaked with sterile normal

saline should be used to cover the wound. The nurse must notify the physician after

applying the initial dressing to the wound. Options 1, 2, and 4 are incorrect.