A nurse is assessing the abdominal wound of a client who is 3 days postoperative following a colon resection. Which of the following findings should the nurse report to the provider?
Purulent drainage
Edema
Ecchymotic skin
Erythema
The Correct Answer is A
A. Purulent drainage: The presence of purulent drainage suggests a possible wound infection, which requires immediate evaluation and potential intervention by the provider. Signs of infection may include increased warmth, redness, swelling, and fever. Culturing the wound and initiating appropriate antibiotic therapy may be necessary.
B. Edema: Mild edema around the surgical site is a common postoperative finding due to localized inflammation and tissue healing. Unless accompanied by other concerning signs like excessive drainage or warmth, it is not typically a cause for alarm.
C. Ecchymotic skin: Bruising around the incision site is expected after surgery due to minor blood vessel trauma during the procedure. It usually resolves without intervention and does not necessarily indicate a complication.
D. Erythema: Some redness around the incision is normal in the early postoperative period as part of the inflammatory response to healing. However, increasing or spreading erythema, particularly with warmth and tenderness, may indicate infection and should be further evaluated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B"]
Explanation
- Wound appearance: The client's wound is consistent in size (3 cm x 4 cm) but the purulent drainage may indicate ongoing infection. However, the key aspect is that the client has a scheduled appointment with a wound care specialist, which suggests that there is a plan in place for managing the wound, indicating that the situation is being monitored and potentially improving with treatment.
- Blood glucose: The blood glucose level decreased from 250 mg/dL two weeks ago to 140 mg/dL today. While still elevated, this reduction indicates better glycemic control, which is essential for overall health and particularly important in the context of healing and managing diabetes.
- WBC: The WBC count increased from 9,500/mm³ to 11,200/mm³. This increase could indicate an ongoing infection or inflammatory process, suggesting that the client's condition is not improving in this regard.
- Urinary frequency: The information provided does not detail any changes in urinary frequency, and given the initial presentation of increased thirst and urination, ongoing monitoring is essential. Without additional context, this does not indicate improvement.
- Temperature: The temperature increased from 38.3°C (100.9°F) to 39.0°C (102.2°F), indicating a worsening state that may suggest infection or systemic response rather than improvement.
- Blood pressure: The blood pressure dropped from 98/74 mm Hg to 90/68 mm Hg, which is concerning and indicates potential hypotension, possibly due to infection or other factors affecting the client’s status.
- Heart rate: The heart rate increased from 104/min to 106/min, suggesting that the client may be experiencing stress, pain, or infection, indicating that their condition may not be improving.
Correct Answer is ["A","B","C","D","E","F"]
Explanation
- Tightness in chest that radiates to left arm: Classic symptom of acute coronary syndrome (ACS), including myocardial infarction (MI). Cardiac pain is often described as pressure, squeezing, or tightness and may radiate to the left arm, jaw, or back.
- Pain rated 7 on a scale of 0 to 10: Severe pain is a hallmark of an MI and suggests significant myocardial ischemia. Persistent or worsening chest pain should prompt urgent intervention.
- Nausea after breakfast: Nausea and gastrointestinal discomfort can be atypical signs of an MI, particularly in individuals with diabetes. The presence of nausea alongside chest pain raises suspicion for cardiac ischemia.
- Diaphoresis and shortness of breath: Sweating and dyspnea are common autonomic responses to myocardial ischemia. The body reacts to decreased cardiac output by activating the sympathetic nervous system, which results in these symptoms.
- Heart rate irregular and tachycardic: Irregular tachycardia suggests possible arrhythmias, which can be triggered by myocardial ischemia and infarction. Life-threatening dysrhythmias are a significant complication of an MI.
- Skin is cool to touch: Cool skin indicates decreased peripheral perfusion, which may result from reduced cardiac output due to myocardial dysfunction. It is a concerning sign of potential hemodynamic instability.
- Lungs clear to auscultation in all lobes: The absence of crackles or other abnormal lung sounds suggests that pulmonary congestion is not currently present.
- Bowel sounds are present in all 4 quadrants: Normal bowel sounds do not indicate any gastrointestinal pathology.
- +1 pedal pulses: Diminished pulses may suggest peripheral vascular disease but are not directly indicative of an acute cardiac event.
- Capillary refill less than 2 seconds: Normal capillary refill indicates adequate peripheral perfusion and does not suggest an immediate concern.
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