While cleansing a client's surgical incision, the nurse observes the incision as seen in the picture. How should the nurse document the appearance of the incision?

Dehiscence present.

Incision healing well.

Infected incision.

Edges approximated.

Answer and Explanation

The Correct Answer is D

A.   Dehiscence refers to the separation or opening of a wound’s edges, usually occurring after surgical closure. This can be due to several factors including infection, mechanical stress, or inadequate wound healing. If the incision shows signs of separation or gaping, this term would be appropriate. However, without a visual description or image, it’s unclear if the incision exhibits these characteristics.
B.   This term implies that the incision is progressing towards recovery with no significant issues such as infection or dehiscence. This documentation is used when the wound appears clean, dry, and without signs of complications.
C.   An infected incision typically shows signs such as increased redness, warmth, swelling, purulent drainage, or an unpleasant odor. If the incision displays these signs, it would be appropriate to document it as infected.
D.   This term indicates that the edges of the incision are closely aligned, which is often used to describe an incision that is healing by primary intention. The edges are expected to come together neatly without separation.

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Correct Answer is D

Explanation

A. Increasing dietary fiber and adding prune juice can help relieve constipation by improving bowel regularity. While this is an important step in managing constipation, it is not the first action to take without understanding the underlying cause or current status of bowel function.
B. Physical activity is important for bowel regularity, especially post-surgery. However, assessing physical activity should come after a more immediate evaluation of the client's bowel status. It is crucial to first determine if there are other underlying issues that need addressing before implementing dietary changes or increasing activity.
C. A digital examination can be necessary to identify fecal impaction, especially if other assessments suggest severe constipation or if the client has not had a bowel movement for several days. However, this is an invasive procedure and should be performed based on preliminary findings from non-invasive assessments.
D. Checking bowel sounds and abdominal tenderness is an essential first step in assessing the client's gastrointestinal status. It helps identify whether there is a lack of bowel movement due to a more severe issue such as bowel obstruction or if it is simply a case of constipation.

A. Assess the client for pain. B. Apply wrist restraints. C. Determine the client's blood pressure. D. Administer a mild sedative.

Correct Answer is A

Explanation

A. Assessing the client for pain is a crucial step because pain can cause disorientation and agitation, especially after surgery. Pain might be a reason for the client's behavior. Addressing pain effectively can help improve the client’s comfort and potentially reduce disorientation and risky behavior.
B. Applying wrist restraints should be considered a last resort and only when other interventions are not effective or if there is an immediate danger to the client. Restraints can increase agitation and potentially lead to other complications.
C. Determining the client's blood pressure can be important, especially if there are concerns about hypotension or other cardiovascular issues that might contribute to disorientation. However, it is usually more effective to first address potential pain or discomfort.
D. Administering a sedative may be appropriate in cases of severe agitation or disorientation, but it should not be the first action. It is essential to first identify and address any underlying causes of the client’s behavior, such as pain, before resorting to pharmacological interventions.

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While cleansing a client's surgical incision, the nurse observes the incision as seen in the picture. How should the nurse document the appearance of the incision?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is completing an assessment of an older adult client recovering from a total hip replacement. The client reports a decreased appetite and is concerned about having not had a bowel movement for several days. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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