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 B
Explanation
Choice A reason
Weight loss is not the correct answer: Weight loss is not a common side effect of simvastatin. In fact, weight loss is generally not associated with statin use. If the client experiences significant, unintentional weight loss, it may indicate another underlying issue that should be reported to the provider.
Choice B reason:
Muscle weakness is the correct answer. The nurse should instruct the client to monitor and report any muscle weakness to the healthcare provider when taking simvastatin. Simvastatin is a statin medication used to lower cholesterol levels in the blood. While statins are generally well-tolerated, they can occasionally cause muscle-related side effects, including muscle weakness or pain.
Rhabdomyolysis, a severe condition characterized by the breakdown of muscle fibres, is a rare but serious side effect of statin use. Muscle weakness may be an early sign of this condition. Therefore, if the client experiences any unexplained or persistent muscle weakness while taking simvastatin, it should be reported to the healthcare provider immediately.
Choice C reason
Fever is not the correct answer: Fever is not a common side effect of simvastatin. If the client develops a fever while taking simvastatin, it is more likely to be related to another condition and should be reported to the provider for further evaluation.
Choice D reason:
Edema is the correct answer: Edema (swelling) is not a common side effect of simvastatin. If the client experiences significant edema, especially in the extremities, it may indicate another underlying issue that should be reported to the provider.
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}
Explanation
The nurse should first administer oxygen at 2 L/min via nasal cannula because the client has signs of hypoxemia (low oxygen saturation) and respiratory distress (increased respiratory rate) that may worsen the chest pain and myocardial ischemia. Oxygen therapy can help improve oxygen delivery to the heart muscle and reduce the workload of the heart.
The nurse should then administer sublingual nitroglycerin as prescribed because nitroglycerin is a vasodilator that can help relieve chest pain by dilating the coronary arteries and improving blood flow to the heart. Nitroglycerin can also lower blood pressure and reduce cardiac preload and afterload, which can decrease myocardial oxygen demand.
Other choices:
• Prepare the client for cardiac catheterization: This may be a later intervention if the chest pain persists or if the client has a confirmed myocardial infarction, but it is not the first priority for the nurse. Cardiac catheterization is an invasive procedure that involves inserting a catheter into a large artery and advancing it to the coronary arteries to visualize any blockages or stenosis. The procedure may also involve angioplasty or stent placement to restore blood flow to the affected area.
• Request a prescription for an increase in statin: This may be a long-term intervention to lower the client’s LDL cholesterol and prevent further plaque formation in the coronary arteries, but it is not an immediate intervention for chest pain. Statins are lipid-lowering drugs that can reduce the risk of cardiovascular events in clients with CAD, but they do not have a direct effect on chest pain or myocardial ischemia.
• Check a STAT cardiac troponin: This may be a diagnostic test to confirm or rule out a myocardial infarction, but it is not an intervention for chest pain. Cardiac troponin is a protein that is released into the bloodstream when there is damage to the heart muscle. Elevated levels of cardiac troponin indicate a myocardial infarction or other cardiac injury.
• Request a prescription for a beta-blocker: This may be an adjunctive therapy to reduce chest pain and prevent complications, but it is not the first-line intervention for chest pain. Beta-blockers are drugs that block the effects of adrenaline on the heart and blood vessels, which can lower heart rate, blood pressure, and myocardial oxygen demand. Beta-blockers can also prevent arrhythmias and reduce mortality in clients with CAD.
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