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 C

Explanation

A) Flushed skin: Flushed skin is not typically associated with hyponatremia. Instead, hyponatremia may present with symptoms such as pallor or cool, clammy skin due to alterations in perfusion and fluid balance.

B) Fever: Fever is not a common manifestation of hyponatremia. Elevated body temperature is typically associated with conditions such as infection or inflammation rather than electrolyte imbalances like hyponatremia.

C) Nausea and vomiting: Hyponatremia, defined as a serum sodium level below 135 mEq/L, can lead to neurological symptoms, including nausea and vomiting. These symptoms occur due to alterations in osmotic pressure and cellular swelling resulting from the relative excess of water compared to sodium in the extracellular fluid. Other neurological symptoms of hyponatremia can include headache, confusion, lethargy, and seizures.

D) Extreme thirst: Extreme thirst, or polydipsia, is more commonly associated with hypernatremia, which is characterized by a serum sodium level above 145 mEq/L. Hypernatremia results from dehydration or a deficit of body water relative to sodium, leading to increased thirst as the body attempts to restore fluid balance.

A. Administer 200 mL of formula during the initial infusion B. Give the initial feeding over 15 min. C. Reconstitute the formula with tap water D. Discard unused formula after 8 hr.

Correct Answer is D

Explanation

A) Administer 200 mL of formula during the initial infusion:
The initial infusion rate for continuous enteral feeding is typically started at a slower rate, often lower than 200 mL, to assess the client's tolerance and prevent complications such as aspiration or dumping syndrome.

B) Give the initial feeding over 15 min:
Continuous enteral feeding is administered slowly over an extended period, usually 24 hours, to ensure gradual delivery of nutrients and minimize the risk of complications such as aspiration or gastrointestinal intolerance. Giving the initial feeding over 15 minutes is too rapid and can lead to adverse events.

C) Reconstitute the formula with tap water:
Reconstituting enteral formula with tap water is not recommended due to the potential risk of contamination with bacteria or other pathogens. It's essential to use sterile water or water that has been specifically purified for enteral feeding to minimize the risk of infection.

D) Discard unused formula after 8 hr:
Unused formula should be discarded after 4 hours, not 8 hours, to reduce the risk of bacterial contamination and ensure the integrity of the enteral nutrition. This practice aligns with guidelines for safe enteral feeding administration.

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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

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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