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
Explanation
A. Reduced cravings: Methadone is a long-acting opioid agonist that helps suppress cravings and withdrawal symptoms in individuals with opioid use disorder. By stabilizing opioid levels in the body, it prevents the compulsive drug-seeking behavior associated with addiction.
B. Somnolence: While methadone can cause sedation, excessive drowsiness is not a therapeutic effect but rather a side effect that may indicate the need for dose adjustment. Therapeutic use should allow normal functioning without excessive sedation.
C. Euphoria: Unlike short-acting opioids, methadone is formulated to prevent euphoria when taken at prescribed doses. Experiencing euphoria may indicate misuse or an excessively high dose rather than a therapeutic response.
D. Dilated pupils: Methadone, as an opioid agonist, typically causes pupil constriction (miosis) rather than dilation. Dilated pupils may indicate withdrawal or intoxication with other substances rather than therapeutic effects of methadone.
Correct Answer is C
Explanation
A. 150 mL of greenish yellow NG drainage: This amount and color of drainage are expected after abdominal surgery, as bile-stained gastric contents can be present. It does not indicate a complication that requires provider notification.
B. Client requests medication for nausea: Nausea is a common postoperative symptom, often managed with antiemetics. While it should be addressed, it is not an urgent finding that requires immediate provider notification.
C. Urinary output of 250 mL over past 12 hr: Oliguria, defined as urine output less than 30 mL/hr (or less than 400 mL in 24 hr), suggests inadequate renal perfusion, possibly due to hypovolemia or acute kidney injury. This finding requires prompt provider notification.
D. Hypoactive bowel sounds: Reduced bowel activity is common after abdominal surgery due to anesthesia and opioid use. While monitoring is necessary, hypoactive sounds alone are not an urgent concern unless accompanied by other signs of ileus or obstruction.
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