A client at a health care facility who underwent an open ...

[vinney12]

A client at a health care facility who underwent an open appendectomy describes to the nurse that he feels like something has given way.
 
  On inspecting the surgical wound, the nurse notes a pinkish drainage on the dressing and a visible separation between the two sides of the incision. What intervention should the nurse perform in this case? A) Position the client to put the least strain on the operated area.
  B) Place sterile dressings moistened with normal saline over the area.
  C) Inform the head nurse immediately about the client's condition.
  D) Inspect and palpate the wound to determine the extent of the secretion.

Question 2

While covering a colleague's lunch break, a nurse on an orthopedic unit has responded to a client's call light. The client has requested assistance in transferring from the bed to the bathroom.
 
  The nurse has not previously provided care for this client and is unsure of the client's current activity orders. The client's current level of activity can be most easily verified by consulting what written source? A) Nursing care plan
  B) Nursing kardex
  C) Checklist
  D) Flow sheet

[at]

Answer to Question 1

A
Feedback:
If wound disruption is suspected, the nurse should position the client to put the least strain on the operated area. The nurse should inform the physician immediately rather than informing the head nurse first. If evisceration occurs, the nurse places sterile dressings moistened with normal saline over the protruding organs and tissues. The nurse must be alert for signs and symptoms of impaired blood flow such as swelling, localized pallor or a mottled appearance, and coolness of the tissue in the area around the wound. Palpation of the wound would be an inappropriate action in this case.

Answer to Question 2

B
Feedback:
The nursing kardex provides a succinct and accessible record of many aspects of a client's current orders. The care plan would address the issue of mobility but may not specify the current orders for the client's activity at this point in recovery. Checklists and flow sheets are not places where current orders are recorded and updated.

[vinney12]

Excellent

[juliaf]

Gracias!