The nurse is caring for a client one week postsurgery. Which finding should the nurse expect to see if the surgical incision is healing properly?
A well approximated Incision site.
Erythema and serosanguineous exudate.
Eschar and slough in the wound.
Beefy red granulation tissue.
The Correct Answer is A
A. A well approximated incision site:
A properly healing surgical incision typically appears well approximated, meaning the wound edges are closely aligned and held together with sutures or staples. This indicates that the wound is healing as expected and that the risk of infection and complications is minimized.
B. Erythema and serosanguineous exudate:
Erythema (redness) and serosanguineous exudate (pinkish fluid composed of serum and blood) can be normal findings in the early stages of wound healing, but they may also indicate inflammation or infection if they persist or worsen over time.
C. Eschar and slough in the wound:
Eschar (dead tissue) and slough (yellow or white necrotic tissue) are signs of tissue necrosis or delayed wound healing. They indicate that the wound is not healing properly and may require intervention such as debridement to remove dead tissue and promote healing.
D. Beefy red granulation tissue:
Beefy red granulation tissue is a sign of the proliferative phase of wound healing and indicates that the wound is healing from the bottom up. While granulation tissue is a positive sign of healing, it typically appears later in the healing process rather than one week post-surgery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The client will demonstrate ability to change the ostomy bag in two days.
This outcome statement focuses on the client's ability to perform a specific task related to ostomy care. While it's important for clients with a colostomy to learn how to change their ostomy bag, in the context of this scenario, where the client has developed hyperglycemia requiring insulin injections, the priority lies in managing their diabetes and adhering to the medication regimen. Therefore, while ostomy care is important, it may not be the most immediate concern.
B. The client will adhere to the medication regimen after discharge.
This outcome statement directly addresses the client's need to manage their hyperglycemia by adhering to the prescribed insulin regimen. Given that the client has developed hyperglycemia requiring insulin injections, ensuring medication adherence is crucial for controlling blood sugar levels and preventing complications associated with uncontrolled diabetes. This choice aligns with the client's health needs and goals following the surgical procedure and the development of hyperglycemia.
C. The client's breath sounds will be auscultated by the nurse every 4 hours.
This outcome statement focuses on monitoring the client's respiratory status by auscultating breath sounds at regular intervals. While respiratory assessment is important, especially postoperatively, it may not directly address the client's primary health concern in this scenario, which is managing hyperglycemia and insulin administration.
D. The client attempts to self-administer insulin but is unable to perform injection.
This outcome statement indicates the client's attempt to self-administer insulin but inability to perform the injection. While it's important for clients to be able to self-administer insulin, the emphasis in this scenario should be on ensuring that the client adheres to the medication regimen, rather than focusing solely on their ability to self-administer insulin immediately after discharge. Therefore, while self-administration of insulin is relevant, it may not be the most immediate priority in the postoperative plan of care.
Correct Answer is D
Explanation
A. Administering the medication to a client behind a closed curtain:
Administering medication behind a closed curtain is not necessarily a tort. However, it may be a breach of privacy depending on the circumstances and the client's preferences.
B. Enlisting security personnel to assist with restraining the client:
Enlisting security personnel to assist with restraining an agitated client is not inherently a tort. It may be necessary to ensure the safety of the client and healthcare providers, depending on the situation.
C. Informing a client that the medication being administered is a vitamin:
Misinforming a client about the medication being administered is not a tort, but it is unethical and can lead to potential harm if the client does not receive appropriate treatment.
D. Placing a client in restraints without having a healthcare provider's order:
This action constitutes a tort known as false imprisonment. Restraints should only be applied when ordered by a healthcare provider and when necessary to ensure the safety of the client or others. Placing a client in restraints without proper authorization can lead to physical and psychological harm and is a violation of the client's rights.
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