Practice Quiz

CRNE Exam Prep

Category - Changes in Health

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Nikki, a female client who had an abdominal surgery a week ago, demonstrates separation of the wound edges at the suture line. Increased drainage and appearance of underlying tissues through the wound are noted. Which of the following is the most appropriate initial nursing intervention for the client?
  1. Cover the wound with a sterile normal saline solution.
  2. Place the client in low Fowler’s position with the knees bent.
  3. Instruct the client to splint the incision.
  4. Notify the physician.
Explanation
Answer: B - The nurse must first place the client in low Fowler’s position with the knees bent. This intervention prevents abdominal tension on the abdominal suture line. Options A, C, and D are appropriate, but they are not the initial action of the nurse. The nurse should also initiate interventions that prevent wound infection and administer anti-emetics to avoid further straining the incision.
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