Question

A nurse caring for a client in the postoperative period following an enucleation, notes bloody staining on the surgical eye dressing. Which of the following is the appropriate initial action?

A. Reinforce the dressing.
B. Remove the dressing.
C. Apply an ice pack.
D. Notify the healthcare provider.

Answer 1

The appropriate initial action when a nurse observes bloody staining on a surgical eye dressing post-enucleation is to reinforce the dressing to prevent further disturbance to the site.

Step-by-step explanation:

If a nurse caring for a client in the postoperative period following an enucleation notes bloody staining on the surgical eye dressing, the appropriate initial action would be to reinforce the dressing. Removal of the dressing could disturb the surgical site and lead to increased bleeding or infection. It is important to maintain the cleanliness and integrity of the surgical dressing, and reinforcement allows additional absorption of any blood. Applying an ice pack or notifying the healthcare provider may be subsequent steps depending on the protocols in place and the amount of bleeding.