The nurse is alert to the indication of possible dehiscence of an abdominal surgical wound, which would be evidenced by:

Increased pallor of the surgical site.

Increased serosanguineous drainage from the wound.

Excessive gas.

Complaint of constipation.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Increased pallor of the surgical site is not a typical sign of wound dehiscence. It could indicate poor blood flow to the area, but it’s not directly related to dehiscence.

Choice B rationale:

Increased serosanguineous drainage from the wound is a common sign of wound dehiscence. This type of drainage is a mixture of blood and serum, and an increase could indicate that the wound edges are separating.

Choice C rationale:

Excessive gas is not a typical sign of wound dehiscence. It could be related to other postoperative complications, such as ileus or bowel obstruction, but not specifically to dehiscence.

Choice D rationale:

Complaint of constipation is not a typical sign of wound dehiscence. It could be related to other postoperative complications, such as side effects of pain medication or decreased mobility, but not specifically to dehiscence.

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Correct Answer is C

Explanation

Choice A rationale:

Stage 3 pressure injuries involve full-thickness skin loss, but not exposure of fascia.

Choice B rationale:

Stage 2 pressure injuries involve partial-thickness loss of skin with exposed dermis.

Choice C rationale:

Stage 4 pressure injuries involve full-thickness skin and tissue loss with exposed or directly palpable fascia.

Choice D rationale:

Stage 1 pressure injuries involve non-blanchable erythema of intact skin.

A. Ask someone to quickly get an abdominal binder. B. Assist the patient in a supine position. C. Seat the patient in a nearby chair. D. Instruct the patient to pant to reduce abdominal tension.

Correct Answer is B

Explanation

Choice A rationale:

Asking someone to quickly get an abdominal binder is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position to prevent further injury.

Choice B rationale:

Assisting the patient to a supine position is the correct action. This is because the patient’s statement may indicate dehiscence (separation of the wound edges), and placing the patient in a supine position with the knees bent can reduce tension on the wound and prevent further injury.

Choice C rationale:

Seating the patient in a nearby chair is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position.

Choice D rationale:

Instructing the patient to pant to reduce abdominal tension is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position.

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The nurse is alert to the indication of possible dehiscence of an abdominal surgical wound, which would be evidenced by:

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Naxlex Comprehensive Predictor Exams

The nurse on the unit is going to perform wound care for her patient.After removing the soiled dressing, the following wound is noted to have full-thickness skin and tissue loss with exposed palpable fascia.

Correct Answer is C

Explanation

A nurse is ambulating a patient in the hall a few days after abdominal surgery, and the patient says, "I think something just let go.”. The initial intervention by the nurse should be to:

Correct Answer is B

Explanation

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The nurse reminds the 85-year-old patient that his healing will be slower because of age-related changes such as: (Select all that apply.)

The nurse clarifies that a vacuum-assisted closure supports healing of a wound by:

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