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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Hyperventilation is a common response to respiratory alkalosis as the body tries to compensate for the high pH by exhaling more carbon dioxide.
Choice B reason: Dyspnea, or difficulty breathing, may be present but is not as specific as hyperventilation for respiratory alkalosis.
Choice C reason: Abdominal pain is not typically associated with respiratory alkalosis.
Choice D reason: Dizziness can be a symptom of respiratory alkalosis due to changes in blood chemistry, but it is less specific than hyperventilation.
Correct Answer is B
Explanation
The correct answer is choice B. Raise the head of the bed.
Choice A rationale:
Increasing the patient’s oral fluid intake is important for hydration and thinning secretions, but it is not the immediate priority when oxygen saturation is critically low.
Choice B rationale:
Raising the head of the bed helps improve lung expansion and facilitates easier breathing, which can quickly improve oxygen saturation levels. This is a critical first step in managing low oxygen saturation.
Choice C rationale:
Initiating humidified oxygen therapy is essential for improving oxygenation, but it should follow the immediate action of raising the head of the bed to optimize breathing.
Choice D rationale:
Encouraging the patient to cough and deep breathe is beneficial for clearing secretions and improving lung function, but it is not the first action to take when oxygen saturation is critically low.
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