When Examining The Wound Of A Client

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When Examining The Wound Of A Client

who had abdominal surgery yesterday, the nurse finds that the wound edges are close together, there is no sign of redness, and there is a slight amount of bright red blood oozing from the incision. What action should the nurse take? A. Record these findings in the client's record. Correct B. Observe closely for possible dehiscence. C. Notify the healthcare provider that the client's wound is producing a sanguineous drainage. D. Increase the IV fluid rate and encourage the client to eat more ice chips.
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A. These are normal findings for one-day postoperative and indicate that the wound is healing by primary intention (A). Dehiscence (B) is separation of a surgical incision, and there is no indication that this is a possibility at this time. Serosanguineous drainage is thin and red and is composed of serum and blood, and this client is not exhibiting this finding, and even if the wound was producing this drainage, the finding does not warrant (C). There is no indication of dehydration, so (D) is not indicated at this time. Category: Fundamentals
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