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    Hesi rn med surg proctored exam

    A surgical incision that is healing by secondary intention develops a thick tan exudate. Which action should the nurse take first?

    Explanation & Rationale

    A. Apply sterile-strips is not the most appropriate action. Steri-strips are typically used for approximating wound edges or supporting sutures, but they are not the first intervention when there is concern about infection or unusual exudate. B. Obtain a wound culture is the correct action. A thick tan exudate may indicate infection or an abnormal healing process. The nurse should obtain a wound culture to identify the presence of infection and guide appropriate treatment. C. Apply a debriding agent is premature without first assessing the wound for infection. Debridement is typically used to remove necrotic tissue, but the priority is to determine whether an infection is present before proceeding with debridement. D. Remove every other suture is not indicated. Sutures should not be removed unless instructed by the healthcare provider, and there is no indication that sutures need to be removed at this time. The focus should be on assessing the wound for infection first.

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