test question!

[BA_anthropology]

So the question asked, what is the FIRST thing the nurse should do if the dressing on a patient who is one day post op abdominal surgery, is saturated in bright red blood. Answers were between a) alert the physician. B) assess the wound. C) take vitals.

Opions??? My first thought was risk of evisceration...

Please excuse grammar in this post; i'm typing from my phone.:-)

Thanks!!!!

[CuriousMe]

So the question asked, what is the FIRST thing the nurse should do if the dressing on a patient who is one day post op abdominal surgery, is saturated in bright red blood. Answers were between a) alert the physician. B) assess the wound. C) take vitals.

Opions??? My first thought was risk of evisceration...

Please excuse grammar in this post; i'm typing from my phone.:-)

Thanks!!!!

My first thought: is the patient is bleeding out?

Of the choices listed I'd take vitals (ie, do they have a perfusing BP?)

One day post-op....I wouldn't take the bandage off to assess the wound...if anything I'd reinforce the bandage.

Call the MD is a good idea, but I'd prefer to be able to tell them a pulse, BP and O2 Sat when I do as they'll likely ask me for them.

[Despareux]

I'm thinking that if it's primary dressing (sounds like it is), then I would not remove it unless there are orders to do so under specific circumstances.

I would take vitals first so that when I speak with the physician, I will have pertinent information that he/she will need anyway.

What's the correct answer?

[BA_anthropology]

You guys are so smart!! Vitals was correct. I chose to assess the wound....oops.

[Despareux]

You guys are so smart!! Vitals was correct. I chose to assess the wound....oops.

In real life, I would want to assess a wound, too. Thank God for nursing school to teach us otherwise.

[CrazierThanYou]

This question was on our exam Monday.

[kgh31386, BSN, MSN, RN]

With the post-op patients I get in real life, you don't wanna take off a surgical dressing unless the MD says so. If it's bleeding and actually soaking through the dressing, just re-inforce it(don't remove it to look at it). I'd have someone call the MD while I re-inforce the dressing. But based on your answers for the test, I'd take some vitals I guess(but have someone page the MD while I did).

[~Mi Vida Loca~RN, ASN, RN]

With the post-op patients I get in real life, you don't wanna take off a surgical dressing unless the MD says so. If it's bleeding and actually soaking through the dressing, just re-inforce it(don't remove it to look at it). I'd have someone call the MD while I re-inforce the dressing. But based on your answers for the test, I'd take some vitals I guess(but have someone page the MD while I did).

Funny enough, my teacher just gave us a really insightful handout regarding taking nclex. It had a question almost identical to this one. They said if you're in school, you chose vitals. Because they always stress the vitals. In NCLEX world, you alert the physician, and in real life you do all 3 simultaneously.

[gpatry]

We had a similar question and the answer for us was to alert the physician

[tokidokifantasy]

I almost wanted to choose assess wounds, but you only do that when you have a doctor's order, so you would need the doc's order first. So the only option is vital sign.

But if you can do all three simultaneously, then really, what is the correct answer to choose on nclex? I feel like some questions are debatable. you can have two correct answers, and when we rationalize to our teacher, she always agree. lol. but of course, you don't get to do that for nclex. I am seeing how some nurses are saying what you learned in nursing school don't always apply to real world. Because every hospital have their own protocols, so you would have to learn things THEIR way. =)

[2ndyearstudent, CNA]

So the question asked, what is the FIRST thing the nurse should do if the dressing on a patient who is one day post op abdominal surgery, is saturated in bright red blood. Answers were between a) alert the physician. B) assess the wound. C) take vitals.

Opions??? My first thought was risk of evisceration...

Please excuse grammar in this post; i'm typing from my phone.:-)

Thanks!!!!

Its a nursing process question. First thing you do is assess the patient. They kind of tried to trick you with using the word "assess" in the B, but you want to find out how the patient is doing.

[CuriousMe]

We had a similar question and the answer for us was to alert the physician

Alert the Physician before taking vitals or finding out anything other than the patient is bleeding?