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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Positive external places are images of pleasant and relaxing environments that can distract the client from the pain and induce a sense of calmness and well-being. Examples of positive external places are a beach, a garden, or a mountain.
Choice B reason: Emotional reflection is a process of exploring and expressing one's feelings and emotions. It may be helpful for some clients to cope with stress and anxiety, but it is not the best focus for guided imagery for chronic pain. Emotional reflection may trigger negative emotions or memories that can worsen the pain perception.
Choice C reason: Motivational phrases are statements that encourage and inspire the client to achieve a goal or overcome a challenge. They may be useful for some clients to boost their self-confidence and self-efficacy, but they are not the best focus for guided imagery for chronic pain. Motivational phrases may not be effective in reducing the pain intensity or duration.
Choice D reason: Tranquil sounds are noises that create a soothing and peaceful atmosphere. They may be helpful for some clients to relax and fall asleep, but they are not the best focus for guided imagery for chronic pain. Tranquil sounds may not be enough to divert the client's attention from the pain or create a positive emotional state.
Correct Answer is A
Explanation
Choice a reason: A 3 mL syringe is the most accurate device for measuring a 2 mL dose of a viscous liquid solution due to its design and gradation precision. Syringes provide clearly marked measurement lines, allowing for highly accurate dosing, especially for amounts as small as 2 mL. For viscous liquids, the controlled plunger mechanism of a syringe ensures smooth and consistent measurement and delivery. This is critical in nursing practice, as even slight deviations in medication dosing can lead to therapeutic failures or adverse effects. Additionally, syringes are designed to handle a variety of liquid viscosities, reducing the likelihood of measurement errors caused by sticking or uneven flow. By eliminating the need for visual estimation common with other tools, the syringe minimizes user error and enhances patient safety. The 3 mL capacity ensures the nurse can measure the exact dose without overloading or underutilizing the equipment, maintaining both precision and ease of use.
Choice b reason: A one-ounce medicine cup is less accurate for measuring a 2 mL dose due to its relatively larger size and less precise measurement gradations. Medicine cups are typically designed for measuring larger volumes, such as 5 mL, 15 mL, or more, and are not ideal for small doses. The wide surface area and less detailed markings make it difficult to accurately align the liquid level to the desired measurement, especially for small amounts like 2 mL. This can result in over- or under-dosing, which is particularly problematic when administering potent medications. Additionally, the open design of medicine cups may make pouring viscous liquids challenging, as the liquid may stick to the sides of the cup, leading to further inaccuracies. While convenient for larger doses or liquid mixtures, the medicine cup does not offer the precision required for small, specific dosages in clinical practice.
Choice c reason: A tuberculin syringe, which has a capacity of 1 mL, is specifically designed for administering very small doses, such as subcutaneous or intradermal injections. Using it for a 2 mL dose is impractical and could lead to dosing errors. The nurse would need to fill the syringe twice to administer the full 2 mL, increasing the risk of cumulative measurement inaccuracies. This approach is also time-consuming and may lead to wastage of the medication, as viscous liquids can leave residue inside the syringe, further complicating the dose calculation. Additionally, the markings on a tuberculin syringe are optimized for fractions of a milliliter, not for whole milliliter increments, making it unsuitable for measuring a 2 mL dose. Using this tool for a dose beyond its designed capacity contradicts best practices in nursing, which emphasize using equipment tailored to the specific requirements of the medication and patient.
Choice d reason: Using a 3 mL syringe with a sterile needle is unnecessary and not recommended for administering an oral medication. While the 3 mL syringe itself is suitable for measuring a 2 mL dose, the inclusion of a sterile needle is irrelevant and introduces an additional risk of improper administration. Oral medications are not meant to be injected, and the presence of a needle could lead to accidental use or injury. Furthermore, sterile needles are specifically intended for invasive procedures, such as intramuscular or intravenous injections, and their inclusion in an oral medication protocol is not only superfluous but also contraindicated. The presence of the needle complicates the preparation process without providing any benefit, detracting from the simplicity and efficiency of administering the medication orally. In nursing practice, ensuring that the equipment matches the route of administration is crucial to patient safety and protocol adherence.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.