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 A

Explanation

A. Raise the bed to a comfortable height:
Raising the bed to a comfortable height is essential for proper body mechanics and preventing back strain. It ensures the nurse can perform the procedure efficiently and safely.

B. Stand on the left side of the bed:
While a left-handed nurse might prefer to stand on the left side for better access, this choice depends on the room layout and client position. Standing on the side where the nurse is most comfortable is essential, but it is not the primary action compared to ensuring proper bed height.

C. Raise the side rail on the working side of the bed:
Raising the side rail on the working side of the bed could obstruct the nurse's access to the client and is not generally recommended during procedures requiring close access to the client.

D. Use the non-dominant hand to insert the catheter:
The dominant hand, in this case, the left hand, should be used to insert the catheter for better control and precision. The non-dominant hand is typically used to hold the genitalia and provide stability.

A. Verify the oxygen flow rate every other day. B. Post NO SMOKING signs in a prominent location in the home. C. Notify local fire department D. Apply petroleum ointment to nares if they become dry and imitated. E. Check the tops of the ears for skin breakdown.

Correct Answer is ["B","C","E"]

Explanation

B. Post NO SMOKING signs in a prominent location in the home:
Oxygen supports combustion, making smoking or exposure to open flames highly dangerous in an oxygen-enriched environment. Posting NO SMOKING signs serves as a reminder to everyone in the household to avoid smoking or using open flames near the oxygen source.

C. Notify local fire department:
It's crucial to inform the local fire department that a client is using home oxygen therapy. This ensures that emergency responders are aware of the presence of oxygen in the home in case of a fire or emergency situation.

E. Check the tops of the ears for skin breakdown:
The nasal cannula can cause pressure on the tops of the ears, potentially leading to skin breakdown, especially with prolonged use. Checking for skin breakdown and providing appropriate skin care helps prevent complications and ensures the client's comfort.

A. Verify the oxygen flow rate every other day:
While it's essential to ensure that the oxygen equipment is functioning properly and that the prescribed flow rate is appropriate for the client's needs, checking it every other day may not be necessary unless there are specific concerns or changes in the client's condition.

D. Apply petroleum ointment to nares if they become dry and irritated:
While it's common for the nasal passages to become dry with oxygen therapy, applying petroleum ointment may not be recommended without consulting the healthcare provider first, as it can interfere with oxygen delivery and increase the risk of infection.

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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 nurse who is left-handed is preparing to perform a straight catheterization for a client. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy via a nasal cannula. Which of the following should the nurse include in the teaching? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

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