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

Answer and Explanation

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

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Correct Answer is D

Explanation

Respiratory acidosis occurs when there is inadequate removal of carbon dioxide (CO2) by the lungs, leading to an accumulation of CO2 and a decrease in pH.

Analysis:

pH 7.22: Indicates acidemia (pH below 7.35), suggesting acidosis.

PaCO2 68 mm Hg: Elevated PaCO2 indicates hypoventilation, which is characteristic of respiratory acidosis.

Base excess -2: Base excess is within normal limits and does not contribute significantly to the acid-base imbalance in this scenario.

PaO2 78 mm Hg: PaO2 is slightly low but not significantly contributing to the acid-base imbalance.

Saturation 80%: Oxygen saturation is low, indicating hypoxemia, which is commonly associated with respiratory acidosis due to hypoventilation.

Bicarbonate 26 mEq/L: Bicarbonate is within normal limits, suggesting compensation for the respiratory acidosis, which is a chronic condition.

Overall, the ABG values indicate respiratory acidosis due to inadequate ventilation, leading to CO2 retention and subsequent acidemia.

A. Tuna B. Tomatoes C. Eggs D. Oranges

Correct Answer is A

Explanation

A) Tuna: Tuna is a major source of magnesium. It is a type of fish that contains a significant amount of this mineral. Magnesium plays a crucial role in various physiological functions, including muscle and nerve function, blood sugar regulation, and bone health. Including tuna in the diet can help maintain adequate magnesium levels.

B) Tomatoes: While tomatoes are nutritious and provide various vitamins and minerals, including potassium and vitamin C, they are not considered a major source of magnesium. Magnesium-rich foods are typically those that are high in seeds, nuts, whole grains, and leafy green vegetables.

C) Eggs: Eggs are a good source of several nutrients, including protein, vitamins, and minerals like vitamin D and choline. However, they are not particularly high in magnesium compared to other foods like nuts, seeds, and leafy greens.

D) Oranges: Oranges are well-known for their vitamin C content and are a good source of dietary fiber. However, they are not considered a major source of magnesium. Magnesium-rich foods are typically those that are more plant-based, such as nuts, seeds, and green leafy vegetables.

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A nurse is caring for a postoperative patient. Which finding will alert the nurse to a potential wound dehiscence?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? PH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Saturation 80% Bicarbonate 26 mEq/L

Correct Answer is D

Explanation

A nurse is conducting a nutritional class on minerals and electrolytes. The nurse should include which of the following foods is a major source of magnesium?

Correct Answer is A

Explanation

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