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:

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.

Choice A reason:

Removing dentures, glasses, contact lenses, jewelry and nail polish is part of the physical preparation of the client before surgery. These items can interfere with the anesthesia, cause injury, or be lost during the procedure.

Choice B reason:

Administering a sedative or anxiolytic medication as prescribed is part of the preoperative medication of the client before surgery. These medications can help reduce anxiety, pain, nausea, and vomiting, and facilitate induction of anesthesia.

Choice C reason:

Marking the surgical site with an indelible marker is part of the patient identification and verification process before surgery. This helps prevent wrong-site, wrong-procedure, or wrong-person surgery by ensuring that the correct site is marked and confirmed by the client, surgeon, and nurse.

Choice D reason:

All of the above. All of these items should be completed before transferring the client to the operating room as part of the preoperative checklist. The checklist ensures that necessary documentation, admission assessment, physical preparation, and client education have been completed before the client enters the surgical suite.