Question

During assessment of the wound of a client with a hernia repair, the nurse notices a protrusion between the 5th and 8th staples. What should the nurse do first?

a. Apply a wet-to-dry dressing
b. Call the client's surgeon
c. Check the client's vital signs
d. Elevate the HOB 30 degrees

Answer 1

The nurse should call the client's surgeon first. Checking the client's vital signs and elevating the HOB should be done after.

Step-by-step explanation:

The nurse should call the client's surgeon first when noticing a protrusion between the 5th and 8th staples in a client with a hernia repair. This is because the surgeon needs to be notified immediately, as it could indicate a complication such as a hernia recurrence or an incisional hernia.

By contacting the surgeon, they can assess the client's condition and determine the appropriate course of action, which may include recommending further examination or intervention.

Checking the client's vital signs and elevating the head of the bed (HOB) 30 degrees are important nursing interventions, but they should be done after notifying the surgeon.