When performing a surgical dressing change of a client's abdominal dressing, the nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse
The priority nursing action at this time is to: 1. Apply a povidone-iodine (Betadine)–soaked sterile dressing.
2. Leave the incision exposed to the air to dry the area.
3. Apply a sterile dressing soaked with normal saline.
4. Irrigate the wound, and apply a dry sterile dressing.
3
Rationale: Wound dehiscence is the separation of wound edges at the suture line. Signs and symptoms include increased drainage and the exposure of underlying tissues. These usually occur 6 to 8 days after surgery. The client should be instructed to remain quiet and to avoid coughing or straining. The client should be positioned to prevent further stress on the wound. Sterile dressings soaked with sterile normal saline should be used to cover the wound. The physician must be notified after applying this initial dressing to the wound.
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a. Less perfusion b. Greater moisture c. More perspiration d. Greater absorption
The nurse manager is concerned about the increased number of medication adverse effects being observed in older patients. What should the manager do to reduce these effects? Select all that apply.
1. Conduct a monthly quality improvement study. 2. Monitor each nurse's ability to detect preparation errors. 3. Discuss the importance of not missing medication doses. 4. Review pharmacy documentation regarding drug—drug interactions. 5. Ensure that the physicians' orders are legible.
Which does the nurse implement to decrease the potential for infection related to IV therapy?
1. Use clean technique for dressing changes. 2. Palpate insertion site through the dressing. 3. Change the IV tubing at 12-hour intervals. 4. Routinely apply an antimicrobial to IV site.
The New York Heart Association and the Canadian Cardiovascular Society have described grading criteria for levels of angina. Angina that occurs with unusually strenuous activity or on walking or climbing stair after meals is class:
1. I 2. II 3. III 4. IV