The nurse is caring for a postoperative client with an abdominal ...

[humphriesbr@me.com]

The nurse is caring for a postoperative client with an abdominal wound and a drain. What can the nurse delegate to unlicensed assistive personnel?
 
  1. Clean the wound.
  2. Assess the skin around the wound.
  3. Determination of effectiveness of pain medication.
  4. Report if the dressing is soiled.
  5. Report if the dressing is loose.

Question 2

The nurse is planning to remove the sutures from a client's surgical wound. What should the nurse do before removing the sutures?
 
  1. Apply clean gloves.
  2. Verify the order for suture removal.
  3. Ambulate the client to the bathroom.
  4. Read the order to determine whether a dressing is to be applied after removal.
  5. Remove the dressing and clean the incision.

[wilsonbho]

Answer to Question 1

Correct Answer: 4,5
Rationale 1: Cleaning a newly sutured wound, especially one with a drain, requires application of knowledge, problem solving, and aseptic technique. This procedure should not be delegated to UAP.
Rationale 2: The nurse is responsible for assessment of the wound.
Rationale 3: The nurse is responsible for evaluation of medication provided.
Rationale 4: The nurse can ask the UAP to report soiled dressings that need to be changed.
Rationale 5: The nurse can ask the UAP to report if the dressing is loose and needs to be reinforced.

Answer to Question 2

Correct Answer: 2,4,5
Rationale 1: The nurse is to apply sterile gloves for suture removal.
Rationale 2: Before removing skin sutures, the nurse should verify that there is an order for suture removal.
Rationale 3: The client is not to be ambulated to the bathroom for suture removal.
Rationale 4: Before removing skin sutures, the nurse should verify whether a dressing is to be applied following the suture removal.
Rationale 5: Before removing skin sutures, the nurse should remove the dressing and clean the incision.