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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A: Hyperkalemia refers to high potassium levels, which can occur in ESKD but does not directly cause shortness of breath, swelling, or crackles in the lungs.
B: Hyponatremia refers to low sodium levels, which can occur in ESKD but does not directly cause the symptoms described.
C: Hypervolemia, or fluid overload, is the most likely cause of the client’s symptoms. ESKD can lead to fluid retention, causing shortness of breath, swelling, crackles in the lungs, and elevated blood pressure.
D: Hypovolemia refers to low blood volume, which would not cause the symptoms of fluid overload described in the client.
Correct Answer is D
Explanation
A: Having the client move in with a family member or close friend can provide emotional support and assistance with daily activities. However, it does not specifically address the safety needs related to hearing loss. While this option can be beneficial, it is not the most direct solution for ensuring the client’s safety in their home environment.
B: Encouraging the client to get a roommate can also provide companionship and assistance. However, like option A, it does not directly address the specific safety concerns associated with hearing loss. The presence of a roommate might help in emergencies, but it is not a guaranteed solution for all safety issues.
C: Increasing the sound on all alarms might seem like a logical step, but it is not effective for someone with full hearing loss. This approach does not ensure that the client will be alerted to emergencies, as they may not hear the alarms regardless of the volume.
D: Installing flashing lights for alarms is the most effective recommendation for a client with full hearing loss. Visual alarms can alert the client to emergencies such as fires or intruders, ensuring their safety. This solution directly addresses the client’s inability to hear auditory alarms and provides a reliable method for emergency alerts.
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