Which nursing entry is most complete in describing a client's ...

[ahriuashd]

Which nursing entry is most complete in describing a client's wound?
 
  1. Wound appears to be healing well. Dressing dry and intact.
  2. Wound well approximated with minimal drainage.
  3. Drainage size of quarter; wound pink, 4  4s applied.
  4. Incisional edges approximated without redness or drainage; two 4  4s applied.

Question 2

The nurse is concerned that the client's midsternal wound is at risk for dehiscence. Which of the following is the best intervention to prevent this complication?
 
  1. Administering antibiotics to prevent infection
  2. Using appropriate sterile technique when changing the dressing
  3. Keeping sterile towels and extra dressing supplies near the client's bed
  4. Placing a pillow over the incision site when the client is deep breathing or cough-ing

[soda0602]

Answer to Question 1

ANS: 4
This is the most complete description of the client's wound. It describes the wound according to characteristics observed and the dressing that covers it. Wounds should be measured using the metric system, not described as the size of objects.

Answer to Question 2

ANS: 4
A strategy to prevent dehiscence is to use a folded thin blanket or pillow placed over an ab-dominal wound when the client is coughing. This provides a splint to the area, supporting the healing tissue when coughing increases the intraabdominal pressure. A client who has an infec-tion is at risk for poor wound healing and dehiscence. However, prophylactic use of antibiotics is not the best intervention to prevent dehiscence. Using appropriate sterile technique is always im-portant to prevent the development of infection but is not the best intervention to prevent dehis-cence.