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 C
Explanation
Rationale:
A. Restrict daily exercise: Clients with heart failure benefit from regular, moderate activity as tolerated to improve cardiac efficiency and prevent deconditioning. Restricting all exercise can worsen functional status and is not recommended unless specifically limited by the healthcare provider.
B. Encourage 3 large meals per day: Large meals can increase cardiac workload and exacerbate heart failure symptoms due to increased blood flow demands during digestion. Smaller, more frequent meals are preferable to reduce strain on the heart.
C. Limit dietary salt intake: Reducing sodium intake helps prevent fluid retention and edema, which can exacerbate heart failure and increase cardiac workload. Teaching clients to limit salt is a key intervention to manage decreased cardiac output and maintain stable fluid balance.
D. Obtain weight once per week: Daily weight monitoring is recommended for clients with heart failure to detect fluid retention early. Weekly weights may delay recognition of sudden fluid accumulation, increasing the risk of decompensation.
Correct Answer is ["B","C","E"]
Explanation
Rationale:
A. Anemia: While anemia affects oxygen delivery and overall health, it is not a direct risk factor for neonatal hypoglycemia. Anemia does not significantly impact the infant’s glucose regulation immediately after birth.
B. Prematurity: Premature infants have limited glycogen stores, immature liver function, and underdeveloped metabolic pathways, making them more prone to hypoglycemia. Their ability to maintain normal blood glucose levels is compromised, increasing the risk of low glucose after birth.
C. Maternal diabetes: Infants born to mothers with diabetes are exposed to high glucose levels in utero, which stimulates fetal insulin production. After birth, this hyperinsulinemia can lead to rapid drops in blood glucose, placing the newborn at high risk for hypoglycemia.
D. Thrombocytopenia: Low platelet count affects coagulation but does not directly influence glucose metabolism or the risk of hypoglycemia in newborns. While it is a clinical concern, it is unrelated to neonatal glucose regulation.
E. Hypothermia: Cold stress increases metabolic demands and glucose utilization in newborns. Hypothermia can accelerate depletion of glycogen stores and impair gluconeogenesis, making it a significant risk factor for hypoglycemia in the neonatal period.
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