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 D

Explanation

A: Proceeding to measure the oral temperature immediately after the client has eaten ice chips is not appropriate. The cold temperature can affect the accuracy of the reading.

B: Documenting that the nurse was unable to measure the client’s temperature is unnecessary. The nurse can take steps to ensure an accurate measurement by waiting.

C: Providing the client a sip of warm water and waiting 5 minutes is not sufficient to counteract the effect of the ice chips on the oral temperature reading.

D: Waiting 30 minutes before measuring the oral temperature is the correct action. This allows time for the oral cavity to return to its normal temperature, ensuring an accurate reading.

A. Lowest abuse potential B. Moderate abuse potential C. Mild abuse potential D. Highest abuse potential

Correct Answer is D

Explanation

A: Schedule I drugs do not have the lowest abuse potential. They are classified as having the highest potential for abuse.

B: Schedule I drugs do not have a moderate abuse potential. They are considered to have a high potential for abuse and no accepted medical use.

C: Schedule I drugs do not have a mild abuse potential. They are classified as having the highest potential for abuse.

D: Schedule I drugs have the highest abuse potential and are not accepted for medical use in the United States. Examples include heroin and LSD.

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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

A nurse is measuring a client’s oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

The nurse is administering a controlled substance that falls into the category of Schedule I. Which of the following displays the appropriate abuse potential for Schedule I drugs?

Correct Answer is D

Explanation

A nurse is developing a plan of care for a client who has a stage pressure ulcer. Which of the following interventions should the nurse include in the plan?

A registered nurse interprets that a scribbled medication order reads 25 mg. The nurse administers 25 mg of the medication to a patient and then discovers that the dose was incorrectly interpreted and should have been 15 mg. Who is ultimately responsible for the error?

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A patient refuses medication. Which is the nurse’s first action?

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A nurse is teaching a client who has a history of falls about home safety. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

A nurse is assessing a client who has hypoxemia for a late sign. Which finding should the nurse expect?