The nurse is assessing a patient's postoperative wound and finds it has separated from the suture line with extrusion of the intestine through the opening. How does the nurse document this finding?
Wound evisceration
Wound dehiscence
Wound infection
Wound tunneling
The Correct Answer is A
Wound evisceration refers to the protrusion of internal organs or tissues through an open wound. In this case, with the separation of the wound and extrusion of the intestine through the opening, it is a clear indication of wound evisceration. It is a surgical emergency that requires immediate medical attention.
Wound dehiscence, on the other hand, refers to the separation or opening of a previously closed surgical incision or wound. It does not involve the extrusion of internal organs or tissues.
Wound infection refers to the presence of infectious microorganisms in the wound, leading to inflammation and other signs of infection.
Wound tunneling refers to the formation of narrow channels or tunnels within the wound, often caused by improper wound healing or infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Pernicious anemia is a type of anemia that occurs due to a lack of intrinsic factor, a protein necessary for the absorption of vitamin B12 (cobalamin) in the digestive system. As a result, patients with pernicious anemia are unable to absorb sufficient amounts of vitamin B12 from dietary sources. The treatment for pernicious anemia involves regular administration of cobalamin (B12) injections to bypass the impaired absorption and provide the necessary vitamin B12 directly.
Oral ferrous sulfate tablets are not the appropriate treatment for pernicious anemia. Ferrous sulfate is a form of iron supplement used to treat iron deficiency anemia, which is different from pernicious anemia.
Iron dextran infusions are also not indicated for pernicious anemia. Iron dextran is used for iron replacement therapy in cases of iron deficiency anemia, but it does not address the underlying issue of vitamin B12 deficiency in pernicious anemia.
Routine blood transfusions may be necessary in some cases of pernicious anemia, especially if the patient is severely anemic. However, the primary treatment for pernicious anemia is cobalamin (B12) injections, which provide the necessary vitamin B12 that the patient is unable to absorb.
Correct Answer is C
Explanation
Prednisone is a corticosteroid medication that can increase blood glucose levels by promoting gluconeogenesis (the production of glucose from non-carbohydrate sources) and reducing glucose utilization in the body. This can lead to elevated blood sugar levels, especially in individuals with diabetes. The client's history of urinary tract infection and the use of Prednisone suggest that the infection might have triggered the development of DKA.
It's important to note that DKA can occur even when a person is taking insulin as prescribed and following their diet carefully if other factors contribute to the development of DKA, such as an underlying infection or the use of certain medications like Prednisone. The nurse should further assess the client's condition and notify the healthcare provider to initiate appropriate management for DKA.
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