Level: Foundational
Difficulty: Easy
Subtopic: Nursing process
NCLEX: After implementing a dressing change, the wound remains red with moderate serous drainage and the client reports…
Nursing fundamentals Basic Care and Comfort Safety and Infection Prevention and Control
Case Study
After implementing a dressing change, the wound remains red with moderate serous drainage and the client reports pain 6/10. What is the nurse's next step?
Question
A. Reassess the wound and pain, compare with expected outcomes, and revise the plan if needed.
B. Document success and close the nursing diagnosis without reassessment.
C. Discharge the client because the dressing change was completed.
D. Apply the same dressing for one week without further assessment.
B. Document success and close the nursing diagnosis without reassessment.
C. Discharge the client because the dressing change was completed.
D. Apply the same dressing for one week without further assessment.
Rationale
Correct answer: A. Reassess the wound and pain, compare with expected outcomes, and revise the plan if needed.
Rationale: Evaluation is reassessing outcomes after intervention; ongoing pain and drainage may require plan revision.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Evaluation is reassessing outcomes after intervention; ongoing pain and drainage may require plan revision.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.