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 B
Explanation
A. A client who has aspiration pneumonia: Pneumonia leads to hypoventilation and carbon dioxide retention, which causes respiratory acidosis. It does not typically result in metabolic alkalosis since it affects gas exchange rather than acid-base balance at the metabolic level.
B. A client who is receiving continuous gastric suctioning: Prolonged removal of gastric secretions depletes hydrochloric acid, leading to an excess of bicarbonate in the blood and resulting in metabolic alkalosis. This is a common cause of alkalosis, along with excessive vomiting or diuretic use.
C. A client who is experiencing an opioid overdose: Opioids depress the respiratory system, reducing ventilation and causing carbon dioxide buildup, leading to respiratory acidosis. This does not cause metabolic alkalosis, as the issue originates in the lungs, not metabolism.
D. A client who has uncontrolled diabetes mellitus: Diabetic ketoacidosis results in excessive production of acidic ketone bodies, which lower blood pH and cause metabolic acidosis. The acid-base disturbance in diabetes is typically acidosis, not alkalosis.
Correct Answer is B
Explanation
A. Fasting blood glucose level: This test provides a snapshot of the client's blood glucose at a single point in time, typically after an overnight fast. While useful for daily monitoring, it does not reflect long-term glycemic control.
B. Glycosylated hemoglobin level: Hemoglobin A1c measures average blood glucose levels over the past 2 to 3 months, making it the most reliable indicator of long-term glycemic control. A target level below 7% is recommended for most individuals with diabetes.
C. Postprandial blood glucose level: This test evaluates blood sugar levels after meals but only provides short-term information about glucose fluctuations rather than an overall picture of glycemic control.
D. Oral glucose tolerance test results: This test is primarily used to diagnose diabetes and gestational diabetes rather than to monitor long-term control in individuals already diagnosed with diabetes.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.