Author Question: Upon responding to the client's call bell, the nurse discovers the client's wound has dehisced. ... (Read 53 times)

sarasara · **on:** Jul 23, 2018

Upon responding to the client's call bell, the nurse discovers the client's wound has dehisced. Initial nursing management includes calling the physician and doing which of the following?

A) Covering the wound area with sterile towels moistened with sterile 0.9 saline
B) Closing the wound area with Steri-Strips
C) Pouring sterile hydrogen peroxide into the abdominal cavity and packing with gauze
D) Holding the wound together until the physician arrives

Question 2

When measuring the size, depth, and wound tunneling of a client's stage IV pressure ulcer, what action should the nurse perform first?

A) Perform hand hygiene.
B) Insert a swab into the wound at 90 degrees.
C) Measure the width of the wound with a disposable ruler.
D) Assess the condition of the visible wound bed.

Jsherida · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Ans: A
If dehiscence occurs, cover the wound area with sterile towels moistened with sterile 0.9 saline. The client should also be placed in the low Fowler's position, and the exposed abdominal contents should be covered as previously discussed. Notify the physician immediately because this is a medical emergency. Do not leave the client alone.

Answer to Question 2

Ans: A
Hand hygiene should precede any wound assessment or wound treatment.