The nurse is caring for a patient with diabetes who had abdominal ...

[CORALGRILL2014]

The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider?
 
  a. Blood glucose 136 mg/dL
  b. Oral temperature 101 F (38.3 C)
  c. Patient complaint of increased incisional pain
  d. Separation of the proximal wound edges by 1 cm

Question 2

A new nurse performs a dressing change on a stage II left heel pressure ulcer. Which action by the new nurse indicates a need for further teaching about pressure ulcer care?
 
  a. The new nurse uses a hydrocolloid dressing (DuoDerm) to cover the ulcer.
  b. The new nurse inserts a sterile cotton-tipped applicator into the pressure ulcer.
  c. The new nurse irrigates the pressure ulcer with sterile saline using a 30-mL syringe.
  d. The new nurse cleans the ulcer with a sterile dressing soaked in half-strength peroxide.

[yifu223]

Answer to Question 1

ANS: D
Wound separation 3 days postoperatively indicates possible wound dehiscence and should be immediately reported to the health care provider. The other findings will also be reported but do not require intervention as rapidly.

Answer to Question 2

ANS: D
Pressure ulcers should not be cleaned with solutions that are cytotoxic, such as hydrogen peroxide. The other actions by the new nurse are appropriate.

[CORALGRILL2014]

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