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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Prone with the legs adducted: Prone positioning is not recommended after hip arthroplasty as it places pressure on the surgical site and does not support proper hip alignment. Adduction of the legs increases the risk of hip dislocation.

B. Side-lying on the affected side: Lying on the operative side can cause pain and increase pressure on the hip joint, which may compromise healing. It is generally recommended to avoid side-lying positions unless specifically advised by the provider.

C. Supine with the head slightly elevated: Keeping the client in a supine position with the head elevated and the legs abducted helps maintain proper hip alignment and reduces the risk of dislocation. A wedge or abduction pillow is often used to prevent the legs from crossing.

D. High-Fowler's with a pillow under the knees: A high-Fowler's position increases hip flexion beyond the recommended 90-degree limit, which can lead to dislocation. Placing a pillow under the knees can also increase the risk of venous stasis and deep vein thrombosis.

A. Hypoactive bowel sounds B. Sinus rhythm with peaked T waves C. Irritability and anxiety D. Shallow respirations

Correct Answer is B

Explanation

A. Hypoactive bowel sounds: Hyperkalemia typically causes increased gastrointestinal motility, leading to hyperactive bowel sounds and diarrhea rather than hypoactive bowel sounds.

B. Sinus rhythm with peaked T waves: Elevated potassium levels affect cardiac conduction, leading to ECG changes such as peaked T waves, prolonged PR intervals, and widened QRS complexes. These findings indicate early hyperkalemia and require immediate attention.

C. Irritability and anxiety: While hyperkalemia can cause neuromuscular symptoms, such as muscle weakness and paresthesia, irritability and anxiety are more commonly associated with hypoglycemia or hypoxia rather than hyperkalemia.

D. Shallow respirations: Severe hyperkalemia can lead to muscle weakness, including respiratory muscles, but this occurs in later stages. Shallow respirations are more commonly associated with conditions like respiratory depression or metabolic alkalosis.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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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?