A nurse is assessing a client who had an appendectomy 24 hours ago. The nurse observes redness, warmth, swelling, and purulent drainage at the incision site. The nurse suspects that the client has developed:

A wound infection.

A wound dehiscence.

A wound evisceration.

A wound hematoma.

Answer and Explanation

The Correct Answer is A

Choice A reason:

A wound infection is the most likely diagnosis for a client who has redness, warmth, swelling, and purulent drainage at the incision site 24 hours after an appendectomy. These are signs of inflammation and infection that indicate the wound is not healing properly. A wound infection can delay wound healing, increase pain, and cause fever and systemic symptoms. A wound infection requires treatment with antibiotics and wound care.

Choice B reason:

A wound dehiscence is a partial or complete separation of the edges of a surgical incision. It usually occurs later than 24 hours after surgery, when the wound is still fragile and weak. A wound dehiscence can be caused by stress on the wound, such as coughing, vomiting, or straining, or by poor wound closure, infection, or malnutrition. A wound dehiscence may present with increased drainage, a visible gap in the incision, or a popping sensation. A wound dehiscence requires immediate medical attention and may need surgical repair.

Choice C reason:

A wound evisceration is a rare but serious complication of a wound dehiscence, where the abdominal organs protrude through the open incision. It is a surgical emergency that requires immediate intervention to prevent organ damage, infection, and shock. A wound evisceration may present with sudden pain, a gush of blood or serous fluid, and visible organs through the wound. The client should lie down with knees bent and cover the wound with a sterile dressing moistened with warm saline until help arrives.

Choice D reason:

A wound hematoma is a collection of blood under the skin or in the deeper tissues that results from bleeding at the surgical site. It usually occurs within the first few hours after surgery and may cause swelling, pain, bruising, and pressure on nearby structures. A wound hematoma can increase the risk of infection and impair wound healing. A small hematoma may resolve on its own, while a large hematoma may need drainage or surgery.

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Correct Answer is D

Explanation

Choice A reason:

Wearing tight-fitting clothing or jewelry on the affected arm is not recommended, but it is not something to avoid completely. Tight-fitting clothing or jewelry can cause swelling (lymphedema) or infection in the arm, but wearing them for short periods of time may be acceptable. The client should be advised to wear loose-fitting clothing and jewelry most of the time and to monitor the arm for any signs of swelling, pain, or redness.

Choice B reason:

Elevating the affected arm above the level of the heart is not something to avoid, but rather something to do frequently. Elevating the arm can help reduce swelling and improve blood flow. The client should be instructed to elevate the arm several times a day for 15 to 30 minutes at a time.

Choice C reason:

Applying moisturizer or sunscreen to the affected arm is not something to avoid, but rather something to do regularly. Moisturizer can help prevent dryness and cracking of the skin, which can increase the risk of infection. Sunscreen can help protect the skin from sun damage, which can also increase the risk of infection and skin cancer. The client should be advised to apply moisturizer daily and sunscreen whenever exposed to the sun.

Choice D reason:

Having blood pressure or blood draws on the affected arm is something to avoid. This is because these procedures can cause injury or infection to the arm, which can lead to lymphedema or other complications. The client should be instructed to inform all health care providers that they had a mastectomy with lymph node dissection and to request that blood pressure or blood draws be done on the other arm or on another part of the body.

Choice E reason:

Performing range-of-motion exercises on the affected arm is not something to avoid, but rather something to do gradually and carefully. Range-of-motion exercises can help restore mobility and flexibility to the arm and prevent stiffness and contractures. The client should be instructed to start doing gentle exercises as soon as possible after surgery and to increase the intensity and duration as tolerated. The client may be referred to a physical therapist for additional guidance and support.

A. "I can resume my normal activities in a week.” B. "I can take acetaminophen for pain relief.” C. "I can shower tomorrow and pat my incisions dry.” D. "I can eat a low-fat diet for the first month.” E. "I can expect some drainage from my incisions.".

Correct Answer is ["E"]

Explanation

Choice A reason:

This statement is correct and does not indicate a need for further teaching. The client can resume normal activities in a week after a laparoscopic cholecystectomy.

Choice B reason:

This statement is correct and does not indicate a need for further teaching. The client can take acetaminophen for pain relief after a laparoscopic cholecystectomy.

Choice C reason:

This statement is correct and does not indicate a need for further teaching. The client can shower the day after surgery and pat the incisions dry to prevent infection.

Choice D reason:

This statement is correct and does not indicate a need for further teaching. The client can eat a low-fat diet for the first month to avoid stimulating the gallbladder and causing pain.

Choice E reason:

This statement is incorrect and indicates a need for further teaching. The client should not expect any drainage from the incisions, as this could indicate infection or leakage of bile. The client should report any drainage to the provider immediately. A) “I can resume my normal activities in a week.” B) “I can take acetaminophen for pain relief.” C) “I can shower tomorrow and pat my incisions dry.” D) “I can eat a low-fat diet for the first month.” E) “I can expect some drainage from my incisions.”

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A nurse is assessing a client who had an appendectomy 24 hours ago. The nurse observes redness, warmth, swelling, and purulent drainage at the incision site. The nurse suspects that the client has developed:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is evaluating the discharge instructions for a client who had a mastectomy with lymph node dissection. The nurse instructs the client to avoid:

Correct Answer is D

Explanation

A nurse is reviewing discharge instructions with a client who had a laparoscopic cholecystectomy. Which of the following statements by the client indicates a need for further teaching? (Select all that apply.)

Correct Answer is ["E"]

Explanation

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