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. From the left to the right across the wound. B. From the outer abdomen toward the wound. C. In a circular motion around the wound, circling to the outside. D. Directly over the wound.

Correct Answer is C

Explanation

Choice A rationale:

Cleaning from left to right across the wound can introduce bacteria from the surrounding skin into the wound, which can lead to infection.

Choice B rationale:

Cleaning from the outer abdomen toward the wound can also introduce bacteria from the surrounding skin into the wound.

Choice C rationale:

Cleaning in a circular motion around the wound, circling to the outside, helps to move bacteria away from the wound and reduce the risk of infection.

Choice D rationale:

Cleaning directly over the wound can disrupt the healing process and potentially introduce bacteria into the wound.

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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

The nurse is performing a dry sterile dressing change for an abdominal wound.The nurse should use a swab to clean:

Correct Answer is C

Explanation

The nurse is caring for a 48-year-old female patient with DM, HTN, and limited mobility.Upon assessment, she notes that there is a pink, viable wound bed, with partial-thickness skin loss.

A nurse is collecting data on a client who has a stage 1 pressure injury.Which of the following findings should the nurse expect?

Many factors aid healing.You assist the patient to specifically improve his healing ability by encouraging (Select all that apply.)

A patient who underwent removal of a breast must be discharged home with a Jackson-Pratt wound drain in place.As the patient demonstrates the procedure for emptying it, the nurse should correct her if she:

A nurse is preparing to assist with irrigating a wound for a client.Which of the following actions should the nurse plan to take?

Chronic wounds that are not healing well may benefit from (Select all that apply.)

A nurse explains that the major purpose of the use of a hydrocolloid dressing is to:

When preparing to change a sterile dressing over an incision, it is most important to remember to: