The nurse is caring for a client one week post-surgery. Which finding should the nurse expect to see if the surgical incision is healing properly?

Eschar and slough in the wound.

A well-approximated incision site.

Beefy red granulation tissue.

Erythema and serosanguineous exudate.

Answer and Explanation

The Correct Answer is B

Choice A reason: Eschar and slough in the wound are not signs of proper healing. They are necrotic tissue that impairs wound healing and increases the risk of infection. They should be removed by debridement to promote wound closure.

Choice B reason: A well-approximated incision site is a sign of proper healing. It means that the edges of the wound are close together and aligned, without gaps or separation. It indicates that the wound is healing by primary intention, which is the fastest and most desirable method of wound healing.

Choice C reason: Beefy red granulation tissue is a sign of healing, but not of proper healing for a surgical incision. It is new tissue that fills the wound bed and consists of blood vessels and connective tissue. It indicates that the wound is healing by secondary intention, which is a slower and less desirable method of wound healing.

Choice D reason: Erythema and serosanguineous exudate are not signs of proper healing. They are signs of inflammation and possible infection. Erythema is redness of the skin around the wound, and serosanguineous exudate is a mixture of blood and serum that drains from the wound. They should be monitored and reported to the health care provider.

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Correct Answer is D

Explanation

Choice A reason: This is an incorrect response as it implies that the healthcare provider will disclose the client's laboratory results to the parents. However, the client is emancipated and has the right to privacy and confidentiality of their medical information. The nurse should respect the client's autonomy and consent.

Choice B reason: This is an incorrect response as it implies that the nurse will share the client's laboratory results with the parents. However, the client is emancipated and has the right to privacy and confidentiality of their medical information. The nurse should respect the client's autonomy and consent.

Choice C reason: This is an incorrect and rude response as it insults the parents and disregards their concern. The nurse should be polite and professional when communicating with the parents. The nurse should explain the legal and ethical reasons for not disclosing the client's medical information.

Choice D reason: This is the correct and respectful response as it informs the parents that the client is emancipated and has the right to privacy and confidentiality of their medical information. The nurse should respect the client's autonomy and consent and only give medical information to the client or their designated representative.

A. Remove the basin of water from the client's bed immediately. B. Add skin cream to the basin of water while the foot is soaking. C. Remind the UAP to dry between the client's toes completely. D. Advise the UAP that this procedure is damaging to the skin.

Correct Answer is A

Explanation

Choice A reason: This is the correct action as it prevents the risk of spillage, scalding, or infection. The basin of water should not be placed on the bed, but on a bedside table or stand. The nurse should also check the temperature of the water and the condition of the client's foot.

Choice B reason: This is an incorrect action as it may cause irritation or allergic reaction. The skin cream should not be added to the basin of water, but applied after the foot is dried and inspected. The nurse should also verify the type and amount of skin cream to be used.

Choice C reason: This is an important action, but not the priority. The UAP should dry between the client's toes completely to prevent fungal growth or maceration. The nurse should also monitor the UAP's technique and provide feedback.

Choice D reason: This is an inaccurate statement. The procedure of soaking the client's foot in a basin of warm water is not damaging to the skin, if done properly and safely. The nurse should explain the rationale and benefits of the procedure to the UAP.

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The nurse is caring for a client one week post-surgery. Which finding should the nurse expect to see if the surgical incision is healing properly?

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Naxlex Comprehensive Predictor Exams

A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client's parents arrive and are asking questions about the client's laboratory results. Which response is best for the nurse to provide?

Correct Answer is D

Explanation

The nurse observes an unlicensed assistive personnel (UAP) who is providing a total bed bath for a confused and lethargic client. The UAP is soaking the client's foot in a basin of warm water placed on the bed. Which action should the nurse take?

Correct Answer is A

Explanation

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