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Home Q & A Board Biology-Related Homework Help Medicine
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Cookie12 Cookie12
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6 years ago
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.
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wrote...
#1
6 years ago
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.
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