While providing surgical wound care on a patient recovering from abdominal surgery, the nurse notes a new onset of green-brown drainage on the dressing that appears to be seeping between the sutures
Which of the following should the nurse do to help this patient? 1. clean the wound and apply a new dressing
2. clean the wound and keep it open to air
3. prepare to have the surgical staples removed since this draining indicates healing
4. immediately notify the physician
4
Rationale: Dressing drainage that is green or brown and appears to be seeping between the sutures is an emergent situation and it is imperative that the nurse notifies the health care provider immediately. Early recognition of an enterocutaneous fistula is crucial to prevent life threatening metabolic, septic, and nutritional complications. The nurse should not clean the wound and apply a new dressing. The nurse should also not clean the wound and keep it open to air. The patient may or may not need to have the surgical staples removed at this time. This wound is not healing.
You might also like to view...
A client with myasthenia gravis is malnourished. What actions to improve nutrition may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Assessing the client's gag reflex b. Cutting foods up into small bites c. Monitoring prealbumin levels d. Thickening liquids prior to drinking e. Weighing the client daily
After telling a mother that her 13-year-old daughter is pregnant, the nurse would expect the mother to respond with which statement?
1. "We had such high hopes for you." 2. "But you have always been a happy child." 3. "I've always liked that boy." 4. "This is just one of those things that happen."
Sudden, bright-red bleeding is normal following surgery
True False
When describing the concept of allostatic load to a group of students, which of the following would the instructor identify as abnormal, indicative of the overall changes of the biologic regulatory system?
A) Nuclear imaging studies B) Laboratory test results C) Bone radiographs D) Cardiac studies