The nurse is caring for a patient who has experienced a total abdominal hysterectomy. Which nursing observation of the incision will indicate the patient is experiencing a complication of wound healing?

The site is hurting.

The site has started to itch.

The site is approximated.

The site has a mass, bluish in color.

Answer and Explanation

The Correct Answer is D

A: Pain at the incision site is expected after surgery and does not necessarily indicate a complication. It is important to assess the level and nature of the pain, but pain alone is not a definitive sign of a wound healing complication.

B: Itching at the incision site can be a normal part of the healing process as the wound closes and new tissue forms. While it can be uncomfortable, it is not typically a sign of a complication.

C: An approximated incision means the edges of the wound are close together and healing well. This is a positive sign and indicates that the wound is healing properly.

D: A mass, bluish in color at the incision site, may indicate a hematoma or infection, both of which are complications of wound healing. This finding requires immediate medical attention to address the underlying issue.

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Correct Answer is C

Explanation

A: Requesting the risk manager to obtain consent for HIV testing from the client is important but should not be the first action. Immediate steps to reduce the risk of infection are more urgent.

B: Completing an incident report is necessary for documentation and follow-up but is not the immediate priority following a needle stick injury.

C: Washing the site of injury with soap and water is the first and most immediate action. This helps to reduce the risk of infection by removing any potential contaminants from the wound.

D: Consenting to post-exposure treatment with antiretroviral medications is important if there is a risk of HIV exposure. However, this should follow the initial step of cleaning the wound.

A. Identify the type of sedative. B. Insert a large-bore IV catheter. C. Ensure an adequate airway. D. Prepare the appropriate antagonist.

Correct Answer is C

Explanation

A: Identifying the type of sedative is important for treatment but is not the immediate priority.

B: Inserting a large-bore IV catheter is necessary for administering medications and fluids but is not the first priority.

C: Ensuring an adequate airway is the priority action. Maintaining airway patency is crucial to prevent respiratory complications and ensure the client receives adequate oxygen.

D: Preparing the appropriate antagonist is important but should follow the immediate action of ensuring an adequate airway.

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The nurse is caring for a patient who has experienced a total abdominal hysterectomy. Which nursing observation of the incision will indicate the patient is experiencing a complication of wound healing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While caring for a client, the nurse experiences a needle stick injury. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is caring for a client who has had a sedative overdose. What is the priority action in caring for this client?

Correct Answer is C

Explanation

The nurse is emptying an ileostomy pouch for a patient. Which assessment finding will the nurse report immediately?

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