Difficulty: Medium
Average Score: 90%
Full-length
The nurse is caring for a postcholecystectomy client who had the T-tube removed this AM. Two hours after removal of the T-tube, the nurse notes that the 4x4 dressing covering the stab site is saturated with dark, greenish-yellow drainage. It is MOST appropriate for the nurse to take which of the following actions?
Correct answer
A
Rationale
Dark, greenish-yellow drainage is expected bile post-T-tube removal, and a saturated dressing indicates ongoing drainage until the wound seals. Replacing with a more absorbent dressing keeps the site clean and dry, preventing infection. Culturing (B) is unnecessary without infection signs, dehiscence (C) is unlikely, and reinforcing (D) risks infection.