A nurse is assessing a client who has an abdominal incision. Which of the following findings should the nurse report to the provider?
Crusting of exudate on the incisional line
Mild swelling under the sutures near the incisional line
Partial separation of the upper part of the incisional line
Pink-tinged coloration on the incisional line
The Correct Answer is C
Rationale:
A. Crusting of exudate on the incisional line: A small amount of dried exudate forming a crust along the incision is a normal part of the healing process and typically does not indicate infection or complication. It protects the tissue underneath and usually resolves with routine hygiene, so it does not require immediate reporting.
B. Mild swelling under the sutures near the incisional line: Mild localized swelling is expected in the early postoperative period due to inflammation and tissue repair. This is a common finding and generally resolves as healing progresses, making it a normal assessment observation.
C. Partial separation of the upper part of the incisional line: Partial dehiscence is a serious complication that can lead to infection, evisceration, or delayed healing. This finding requires prompt notification of the provider for immediate intervention, which may include wound closure, protective dressing, or surgical management.
D. Pink-tinged coloration on the incisional line: Light pink coloration along the incision indicates normal healing and adequate perfusion of the tissue. It reflects healthy granulation tissue formation and is expected in the early stages postoperatively, so it does not require urgent reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Disulfiram: Disulfiram is used to support alcohol abstinence by causing unpleasant reactions when alcohol is consumed. It does not reverse opioid overdose and is not indicated for morphine toxicity.
B. Naloxone: Naloxone is an opioid antagonist that binds to opioid receptors and rapidly reverses the effects of morphine and other opioids. It is the first-line treatment for opioid overdose, effectively restoring respiratory function and alertness.
C. Activated charcoal: Activated charcoal can adsorb certain ingested toxins in the gastrointestinal tract, but it is not effective for opioids already absorbed systemically, such as in a morphine overdose.
D. Flumaren: Flumazenil (Flumaren) is a benzodiazepine antagonist used to reverse benzodiazepine overdose, not opioid toxicity. It has no effect on morphine or other opioids.
Correct Answer is A
Explanation
A. Placing the cap sterile-side up on a clean surface prevents contamination of the inside of the cap and maintains the sterility of the solution. This step is essential before pouring to ensure the solution remains sterile.
B. Holding the bottle in the center of the sterile field risks contaminating the field if solution drips; the bottle should be held above or beside the field, not directly over it.
C. Placing sterile gauze over spilled solution does not restore sterility; contaminated areas must be replaced or discarded.
D. Holding the bottle with the label facing away from the palm helps protect the label, but it does not directly affect the sterility of the solution during pouring.
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