Author Question: The nurse is walking a postoperative patient in the hallway when she notices a large red stain of ... (Read 72 times)

mrsjacobs44 · **on:** Jul 23, 2018

The nurse is walking a postoperative patient in the hallway when she notices a large red stain of fresh blood on the patient's gown over the abdominal incision. The patient states, I felt something just ripped open.

What is the priority action of the nurse?
a.
Lift up the patient's gown and assess the incision.
b.
Assist the patient to the floor and call for assistance.
c.
Return the patient to bed and irrigate the wound with sterile saline.
d.
Check the patient's vital signs and pulse oximetry.

Question 2

The nurse is caring for a postoperative patient on his first day after surgery. The nurse informs the patient that the plan is to sit in the chair and ambulate in the hallway. The patient states that he is in pain and he has no intention of getting out of

bed. What is the nurse's best response?
a.
It's important to move around so you don't get a blood clot in your leg.
b.
Your doctor ordered that you are to get out of bed at least twice every day.
c.
I understand. You can rest in bed until tomorrow when the pain is better.
d.
I will call the doctor and let him know that you do not want to get up.

vboyd24 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: B
The large red blood stain over the incision and feeling of ripping open most likely indicates that the patient's wound has dehisced or eviscerated. The nurse should immediately lower the patient to the floor to reduce tension on the wound. Patient modesty and privacy should be maintained, so the incision should be assessed once the patient is transported back to his room. Checking the patient's vital signs and pulse oximetry can be performed once the patient has been lowered to the floor.

Answer to Question 2

ANS: A
The nurse should teach the patient why it is important to ambulate after surgery to prevent postoperative deep vein thrombosis (DVT) formation. Simply telling the patient that the physician ordered ambulation is not sufficient. Allowing the patient to stay in bed will increase the risk of DVT.