A nurse is caring for a postoperative patient. Which finding will alert the nurse to a potential wound dehiscence?
Chronic drainage of fluid through the incision site
Report by patient that something has given way
Drainage that is odorous and purulent
Protrusion of visceral organs through a wound opening
The Correct Answer is B
A. Chronic drainage of fluid through the incision site:
While chronic drainage of fluid through the incision site can be a sign of wound complications, such as infection or poor wound healing, it is not as specific an indicator of impending wound dehiscence as the patient's report of "something giving way."
B. Report by patient that something has given way:
A patient reporting that something has given way is a significant indicator of potential wound dehiscence. Wound dehiscence refers to the partial or complete separation of the layers of a surgical wound, which can occur due to various factors such as poor wound healing, infection, or increased intra-abdominal pressure. Patients may describe a sensation of "something giving way" or "popping" if the wound starts to separate.
C. Drainage that is odorous and purulent:
Odorous and purulent drainage from an incision site may indicate an infection, which can contribute to wound dehiscence. However, this finding alone may not necessarily indicate immediate wound dehiscence.
D. Protrusion of visceral organs through a wound opening:
Protrusion of visceral organs through a wound opening is a severe complication known as evisceration, which is the most advanced stage of wound dehiscence. While this finding is indicative of a significant wound complication, it typically occurs after the initial separation of wound layers. Therefore, it is not an early sign that would alert the nurse to potential wound dehiscence
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "It will be a change for you, but a normal lifestyle is still possible. What concerns you the most?": This response acknowledges the patient's feelings while offering reassurance that life can still be fulfilling after surgery. It also invites the patient to express their concerns, allowing the nurse to address specific worries and provide tailored support.
B. "How has your husband reacted to the news?": While understanding the patient's support system is important, this response does not directly address the patient's expressed feelings of disbelief and may not be the most immediate concern for the patient at this moment.
C. "Don't worry. Many patients have had this same surgery and learn to manage very well.": While meant to offer reassurance, this response may come across as dismissive of the patient's feelings of disbelief and anxiety about the upcoming surgery.
D. "You sound like you are in disbelief. Why do you feel this way?": This response acknowledges the patient's expressed emotion but may come across as confrontational or probing, potentially making the patient feel defensive. It's important to provide support and reassurance while inviting the patient to share their concerns in a non-threatening manner.
Correct Answer is A
Explanation
A. Continue to talk to the client as if they are awake: Even though the client is unresponsive, hearing can be the last sense to diminish as death approaches. Speaking to the client in a calm and reassuring manner can provide comfort and a sense of presence, even if the client cannot respond verbally.
B. Limit the client's visitors to one at a time: While it's important to manage visitors to prevent overwhelming the client, limiting them to one at a time may not be necessary if the client's condition allows for multiple visitors and the client's wishes or cultural preferences support it.
C. Avoid touching the client: Touch can be a powerful form of communication and comfort, even for an unresponsive client. Gentle touch can convey warmth and support to both the client and their family members.
D. Whisper when talking in the client's room: Whispering may create a sense of unease or anxiety for the client or their family members. Speaking in a calm and soothing voice at a normal volume is more appropriate and can help create a peaceful environment for the client's end-of-life care.
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