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: Intact skin with localized erythema describes a stage 1 pressure injury, where the skin is not broken but shows signs of redness and irritation. This stage does not involve any loss of skin layers.
B: Full-thickness skin loss with visible adipose tissue is characteristic of a stage 3 pressure injury. At this stage, the injury extends through the full thickness of the skin and exposes fat tissue, but not muscle, bone, or tendon.
C: Partial-thickness skin loss with red tissue in the wound bed is indicative of a stage 2 pressure injury. This stage involves damage to the epidermis and dermis, resulting in a shallow, open wound with a red or pink wound bed. It may also present as an intact or ruptured blister.
D: Full-thickness skin loss with visible bone describes a stage 4 pressure injury. This stage involves extensive destruction, with tissue loss extending to muscle, bone, or supporting structures.
Correct Answer is C
Explanation
A: Securing the restraints to the lowest bar of the side rail is incorrect. Restraints should be secured to the bed frame, not the side rail, to prevent injury.
B: Ensuring four fingers fit under the restraints is too loose. The correct fit is typically two fingers to ensure the restraint is secure but not too tight.
C: Securing the restraints using a quick-release tie is correct. This allows for quick removal in case of an emergency.
D: Anticipating removing the restraints every 4 hours is incorrect. Restraints should be checked and potentially removed more frequently, typically every 2 hours, to assess skin integrity and circulation.
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