The nurse is caring for a client with a surgical incision and identifies the following assessments: Incision edges are intact. The area around incision is red and edematous. An increase in serosanguinous drainage is noted from yesterday. Which complication does the nurse anticipate is occurring?

Hemorrhage

Wound infection

Wound dehiscence

Fistula development

Answer and Explanation

The Correct Answer is B

A. Hemorrhage: This complication involves acute, profuse blood loss from damaged vascular structures within the surgical site. Clinical manifestations typically include hematoma formation, hypovolemia, or bright red sanguineous output. The presence of intact edges and serosanguinous fluid contradicts active arterial or venous bleeding.

B. Wound infection: Pathogenic colonization triggers an inflammatory response characterized by localized erythema and edema around the incision. Increased serosanguinous or purulent exudate reflects the body's immunological reaction to microbial invasion. These clinical markers are classic precursors to localized sepsis or abscess formation.

C. Wound dehiscence: This mechanical failure involves the partial or total separation of previously approximated wound layers. While serosanguinous drainage can precede this event, the question specifically states the incision edges remain intact. Therefore, the structural integrity of the wound has not yet been compromised.

D. Fistula development: This represents the formation of an abnormal passage between two internal organs or an organ and the skin. It usually results from chronic inflammation, malignancy, or severe infection rather than acute post-operative edema. The localized symptoms described are more indicative of a superficial or deep infection.

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Correct Answer is B

Explanation

A. Arterial ulcer: These ulcers result from inadequate blood supply and are characterized by a lack of drainage and intense pain that is exacerbated by elevation. The "copious amounts of drainage" described in the question is the exact opposite of the dry, necrotic appearance typical of arterial insufficiency. They require gravity-dependent positioning for comfort.

B. Venous ulcer: Chronic venous insufficiency leads to high hydrostatic pressure, which forces fluid into the interstitial space, resulting in heavy exudate or "copious drainage." Elevating the leg reduces this pressure and facilitates venous return, which directly relieves the associated aching pain. These findings are classic diagnostic indicators for venous etiology.

C. Unstageable pressure injury: This classification is reserved for wounds where the base is completely covered by slough or eschar, making depth determination impossible. It does not describe the vascular or exudative characteristics of the wound. The description provided focuses on physiological symptoms rather than the visual obstruction of the wound bed.

D. Stage 3 pressure injury: This stage involves full-thickness skin loss where subcutaneous fat may be visible, but bone or tendon is not. While a Stage 3 injury can have drainage, the specific relief of pain with elevation is a systemic vascular finding rather than a characteristic of localized pressure damage. It lacks the defining features of venous stasis.

A. "When you aren't up and moving your bladder becomes hyperactive, the increased bladder activity can cause urine to overflow." B. "When you lay in bed for extended periods, your bladder, which is made of muscle, can lose its tone, resulting in loss of control." C. "When you lay in a flat position for too long, pressure builds up in the bladder causing spasms and urine leakage." D. "When you don't get enough fluids, your bladder doesn't fill enough causing a loss of muscle tone and control."

Correct Answer is B

Explanation

A. "When you aren't up and moving your bladder becomes hyperactive, the increased bladder activity can cause urine to overflow.": Hyperactivity and overflow incontinence are distinct pathophysiological mechanisms. Immobility does not typically trigger detrusor instability or hyperactive contractions. Overflow is usually caused by an obstruction or an acontractile bladder rather than simple physical inactivity.

B. "When you lay in bed for extended periods, your bladder, which is made of muscle, can lose its tone, resulting in loss of control.": Prolonged immobility leads to deconditioning of the detrusor muscle and the pelvic floor. In the elderly, bed rest rapidly diminishes the ability of the bladder to store urine effectively and maintain urethral pressure. This explains the sudden onset of functional and urge-related incontinence.

C. "When you lay in a flat position for too long, pressure builds up in the bladder causing spasms and urine leakage.": While supine positioning can change intra-abdominal pressure, it does not cause localized bladder spasms in a healthy organ. The issue is more related to global muscle atrophy and loss of neurological coordination. Spasms are usually indicative of infection or irritation.

D. "When you don't get enough fluids, your bladder doesn't fill enough causing a loss of muscle tone and control.": Low fluid intake actually irritates the bladder lining due to concentrated urine, potentially causing urgency, but it does not cause muscle tone loss. Incontinence in an immobile post-operative patient is primarily a result of skeletal and smooth muscle deconditioning.

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The nurse is caring for a client with a surgical incision and identifies the following assessments: Incision edges are intact. The area around incision is red and edematous. An increase in serosanguinous drainage is noted from yesterday. Which complication does the nurse anticipate is occurring?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Correct Answer is B

Explanation

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