A nurse is assessing the abdominal wound of a client who is 3 days postoperative following a colon resection. Which of the following findings should the nurse report to the provider?
Purulent drainage
Edema
Ecchymotic skin
Erythema
The Correct Answer is A
A. Purulent drainage: The presence of purulent drainage suggests a possible wound infection, which requires immediate evaluation and potential intervention by the provider. Signs of infection may include increased warmth, redness, swelling, and fever. Culturing the wound and initiating appropriate antibiotic therapy may be necessary.
B. Edema: Mild edema around the surgical site is a common postoperative finding due to localized inflammation and tissue healing. Unless accompanied by other concerning signs like excessive drainage or warmth, it is not typically a cause for alarm.
C. Ecchymotic skin: Bruising around the incision site is expected after surgery due to minor blood vessel trauma during the procedure. It usually resolves without intervention and does not necessarily indicate a complication.
D. Erythema: Some redness around the incision is normal in the early postoperative period as part of the inflammatory response to healing. However, increasing or spreading erythema, particularly with warmth and tenderness, may indicate infection and should be further evaluated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Prone with the legs adducted: Prone positioning is not recommended after hip arthroplasty as it places pressure on the surgical site and does not support proper hip alignment. Adduction of the legs increases the risk of hip dislocation.
B. Side-lying on the affected side: Lying on the operative side can cause pain and increase pressure on the hip joint, which may compromise healing. It is generally recommended to avoid side-lying positions unless specifically advised by the provider.
C. Supine with the head slightly elevated: Keeping the client in a supine position with the head elevated and the legs abducted helps maintain proper hip alignment and reduces the risk of dislocation. A wedge or abduction pillow is often used to prevent the legs from crossing.
D. High-Fowler's with a pillow under the knees: A high-Fowler's position increases hip flexion beyond the recommended 90-degree limit, which can lead to dislocation. Placing a pillow under the knees can also increase the risk of venous stasis and deep vein thrombosis.
Correct Answer is ["B","D","E"]
Explanation
- "The iron supplement might cause my stools to be black.": This statement is correct as one of the common side effects of iron supplementation is darkening of the stools. This occurs due to the unabsorbed iron and is generally harmless, but clients should be educated about this to avoid confusion with gastrointestinal bleeding.
- "I should increase green leafy vegetables in my diet.": Green leafy vegetables are excellent sources of iron, particularly non-heme iron, which can help improve the client's iron levels. Encouraging a diet rich in iron-rich foods is essential for effective management of iron deficiency anemia, especially for clients on a vegan diet.
- "I will take my iron supplement 1 hour before a meal.": Taking iron supplements on an empty stomach enhances absorption. Clients should be instructed to take the supplement ideally 1 hour before meals or 2 hours after meals for optimal efficacy, unless gastrointestinal discomfort occurs.
- "I should expect to have swelling in my feet.": This statement is not appropriate. Swelling in the feet may indicate fluid retention or other medical issues that should be reported. It is not a typical or expected side effect of iron supplementation or iron deficiency anemia.
- "The iron supplement might cause ringing in my ears.": Ringing in the ears (tinnitus) is not a common side effect of iron supplements. If a client experiences this symptom, it may be related to other factors or medications and should be investigated further.
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