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    RN Comprehensive predictor 2023 proctored exam

    A nurse is assessing a client who is immediately postoperative following abdominal surgery. The nurse notes serosanguineous drainage on the dressing. Which of the following actions should the nurse take?

    Explanation & Rationale

    A. Remove the surgical dressing and obtain a culture: Removing the dressing immediately is unnecessary for routine serosanguineous drainage, which is a normal finding in the early postoperative period. Cultures are only indicated if there are signs of infection such as purulent drainage, redness, or odor. B. Irrigate the incision with saline: Irrigation is not required for normal serosanguineous drainage and may disrupt the healing process. It is reserved for wounds with debris, infection, or specific provider orders. C. Clean the wound with hydrogen peroxide: Hydrogen peroxide can damage healthy tissue and delay healing. It is not indicated for routine postoperative care and should be avoided for normal drainage. D. Mark the outline of the drainage: Marking the outline of the drainage allows the nurse to monitor for changes in amount and size over time. Tracking progression helps identify potential complications such as excessive bleeding or infection and supports timely interventions.

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