A nurse is caring for a patient who has a surgical wound. Which of the following factors places the patient at risk for dehiscence? Select all that apply.

Poor nutritional status

Medication administration

Obesity

Nonadherence

Increased metabolic rate

Answer and Explanation

The Correct Answer is A

Choice A reason: Poor nutritional status can impair wound healing and increase the risk of wound dehiscence.

Choice B reason: Medication administration is too vague to determine a risk for dehiscence without specifying the type of medication.

Choice C reason: Obesity can increase the risk of dehiscence due to the strain on the wound from excess tissue.

Choice D reason: Nonadherence could contribute to dehiscence if it refers to not following postoperative care instructions, but it is not specific enough in this context.

Choice E reason: An increased metabolic rate can lead to higher demands on the body's healing process, potentially aﬀecting wound integrity.

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Correct Answer is A

Explanation

Choice A reason: Elevating the patient in a high Fowler's position can help improve lung expansion and oxygenation, and using an incentive spirometer along with coughing can help prevent atelectasis and pneumonia, which are common postoperative complications.

Choice B reason: Increasing oxygen to 70% without a specific indication could lead to oxygen toxicity, especially without assessing the patient's current oxygenation status.

Choice C reason: Switching to a rebreather mask is not indicated based on the given ABG results and could lead to CO2 retention.

Choice D reason: Positioning the patient prone and performing postural drainage are not typically first-line interventions for a patient one day post-thoracotomy and could be contraindicated due to the recent surgery.

A. Verify that the patient is giving consent voluntarily. B. Explain the amount of pain the patient will have following the procedure. C. Tell the patient the names of other health care providers who will participate in the surgery. D. Inform the patient of the possible outcomes if they do not receive the treatment.

Correct Answer is A

Explanation

Choice A reason: It is essential to ensure that the patient's consent is given freely without coercion. This is a fundamental ethical principle in healthcare.

Choice B reason: While it is important to discuss postoperative expectations with the patient, explaining the amount of pain is not part of the informed consent process but rather part of preoperative education.

Choice C reason: Providing the names of the healthcare team members is not a required element of informed consent, although it may be part of the broader communication with the patient.

Choice D reason: Discussing the consequences of not undergoing the procedure can be part of the informed consent process, but the primary action is to confirm voluntary consent.

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A nurse is caring for a patient who has a surgical wound. Which of the following factors places the patient at risk for dehiscence? Select all that apply.

Nursing Test Bank

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