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","C","D","E"]

Explanation

Choice A reason: Performing deep breathing exercises every 2 hours helps prevent postoperative complications such as pneumonia and atelectasis.

Choice B reason: While chest movement is part of breathing, the instruction is incomplete and should emphasize diaphragmatic breathing rather than shoulder movement.

Choice C reason: Taking a deep breath before coughing helps to increase the eﬀectiveness of the cough, which can clear secretions from the lungs.

Choice D reason: Sitting up straight before beginning coughing exercises helps to ensure maximum lung expansion and eﬀectiveness of the cough.

Choice E reason: Using a pillow to support the surgical area when coughing can help reduce pain and protect the incision site, making the cough more eﬀective.

A. The patient who has advance directives B. The patient's son, who has a durable power of atorney C. The patient's daughter, who is the primary caregiver D. The patient's nurse, who assists with care

Correct Answer is B

Explanation

Choice A reason: Advance directives are instructions given by the patient for future care, not for giving consent for current procedures.

Choice B reason: A durable power of atorney for healthcare allows an individual to make medical decisions on behalf of the patient if they are unable to do so themselves.

Choice C reason: Being the primary caregiver does not automatically grant the legal authority to give consent for medical procedures.

Choice D reason: The nurse's role is to facilitate the consent process, not to give consent on behalf of the patient.

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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

Naxlex Comprehensive Predictor Exams

A nurse is providing preoperative teaching about breathing exercises to a patient. Which of the following instructions should the nurse include? Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

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Correct Answer is B

Explanation

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