Question

A nurse is caring for a client following enucleation. On data collection, the nurse notes staining and bleeding on the dressing. The nurse should take which appropriate action?

A. Reinforce the dressing and notify the healthcare provider.
B. Remove the dressing to assess the surgical site.
C. Apply ice to the affected eye.
D. Document the findings as expected postoperative changes.

Answer 1

After noting staining and bleeding on the dressing following enucleation, the nurse should reinforce the dressing and notify the healthcare provider.

Step-by-step explanation:

When a nurse notes staining and bleeding on the dressing after enucleation, the appropriate action would be to reinforce the dressing and notify the healthcare provider (option A). Staining and bleeding could indicate a complication or an issue with the surgical site, and it is important to inform the healthcare provider for further evaluation and management. Removing the dressing to assess the surgical site (option B) could disturb the healing process and is not recommended without healthcare provider guidance.