A nurse is assessing a client who has an abdominal incision.
Which of the following findings should the nurse report to the provider?
Mild swelling under the sutures near the incisional line.
Crusting of exudate on 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
Wound dehiscence can lead to infection, bleeding, and evisceration (protrusion of internal organs through the incision). The nurse should report this finding to the provider immediately and cover the wound with a sterile dressing moistened with sterile saline solution.
Choice A is wrong because mild swelling under the sutures near the incisional line is a normal finding in the early stages of wound healing. It does not indicate infection or dehiscence unless accompanied by other signs such as redness, warmth, pain, or purulent drainage.
Choice B is wrong because crusting of exudate on the incisional line is also a normal finding that indicates the formation of a scab.
A scab protects the wound from infection and helps it heal faster. The nurse should not remove the scab unless instructed by the provider.
Choice D is wrong because pink-tinged coloration on the incisional line is another normal finding that shows healthy granulation tissue.
Granulation tissue is new tissue that fills in the wound and helps it close. It is usually pink or red and moist.
The nurse should follow these general tips for postoperative abdominal incision care:
- Always wash your hands before and after touching your incisions.
- Inspect your incisions and wounds every day for signs your healthcare provider has told you are red flags or concerning.
- Look for any bleeding.
If the incisions start to bleed, apply direct and constant pressure to the incisions.
- Avoid wearing tight clothing that might rub on your incisions.
- Try not to scratch any itchy wounds.
- You can shower starting 48 hours after your operation but no scrubbing or soaking of the abdominal wounds in a tub.
- After the initial dressing from the operating room is removed, you can leave the wound open to air unless there is drainage or you feel more comfortable with soft gauze covering the wound.
- Surgical glue (Indermil) will fall off over a period of up to 2-3 weeks.
Do not put any topical ointments or lotions on the incisions.
- Do not rub over the incisions with a washcloth or towel.
- No tub baths, hot tubs, or swimming until evaluated at your clinic appointment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C, frequent swallowing.
This indicates that the child may be experiencing hemorrhage because they are trying to clear the blood from their throat. Frequent swallowing is one of the initial signs of bleeding immediately after tonsillectomy.
Choice A is wrong because elevated pain level is not a specific sign of hemorrhage.
Pain is expected after a tonsillectomy and can be managed with medication and fluids.
Choice B is wrong because increased drowsiness is not a specific sign of hemorrhage.
Drowsiness can be caused by anesthesia, medication, or dehydration.
Choice D is wrong because diminished breath sounds are not a specific sign of hemorrhage.
Diminished breath sounds can be caused by respiratory infection, asthma, or bronchospasm.
Normal ranges for hemoglobin and hematocrit are 11.5 to 15.5 g/dL and 34 to 45% for children, respectively.
Normal ranges for platelet count are 150,000 to 450,000/mm3 for both children and adults.
Normal ranges for plasma clotting variables depend on the specific test and method used.
Correct Answer is C
Explanation
Explore
The correct answer is choice c. Contractions.
Choice A rationale:
Epigastric pain is not a common complication following an amniocentesis. It is more often associated with conditions like preeclampsia or gastrointestinal issues.
Choice B rationale:
Hypertension is not directly related to amniocentesis. It is more commonly associated with conditions like preeclampsia or chronic hypertension in pregnancy.
Choice C rationale:
Contractions are a significant complication to monitor for after an amniocentesis, especially at 33 weeks of gestation. The procedure can sometimes induce preterm labor.
Choice D rationale:
Vomiting is not a typical complication following an amniocentesis. It may occur due to other unrelated reasons but is not directly linked to the procedure.
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