A nurse is caring for a client following an open colectomy. Which of the following findings places the client at risk for delayed wound healing?

INR 1.1

Hyperemesis

HbA1C 5.6%

Uncontrolled pain

Answer and Explanation

The Correct Answer is B

- A: An INR of 1.1 is within the normal range, indicating normal blood clotting ability, which is essential for wound healing. A normal INR does not pose a risk for delayed wound healing.
- B: Hyperemesis can lead to dehydration and malnutrition, both of which are detrimental to wound healing. Dehydration reduces blood volume and flow, impairing the delivery of oxygen and nutrients to the wound site, while malnutrition can weaken the immune response and the formation of new tissue.
- C: An HbA1C level of 5.6% is at the high end of the normal range and does not typically indicate diabetes or impaired glucose control, which are risk factors for delayed wound healing.
- D: While uncontrolled pain can be a concern for patient comfort and may indirectly affect wound healing by reducing mobility, it is not a direct risk factor for delayed wound healing like hyperemesis is.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. "Rub your child's gums with an aspirin tablet before bedtime." - Aspirin is not recommended for children due to the risk of Reye's syndrome, a potentially fatal condition.

B. "Place an amber teething necklace on your child before bedtime." - Amber teething necklaces pose a choking hazard and are not recommended for infants.

C. "Administer acetaminophen drops to your child before bedtime." - Acetaminophen is a safe and effective pain reliever for infants and can help alleviate discomfort associated with teething, which may improve sleep.

D. "Apply a teething product containing benzocaine to your child's gums before bedtime." -

Benzocaine-containing products are not recommended for infants due to the risk of methemoglobinemia, a potentially life-threatening condition.

A. Infuse 0.9% sodium chloride IV. B. Administer an antipyretic. C. Decrease the infusion rate to 75 mL/hr. D. Place the client in a left lateral position.

Correct Answer is A

Explanation

A. Infuse 0.9% sodium chloride IV - In the event of a hemolytic reaction, it's important to stop

the blood transfusion immediately and infuse normal saline to maintain intravascular volume and support renal perfusion.

B. Administer an antipyretic - While fever may occur with a hemolytic reaction, the priority is to stop the transfusion and provide supportive care with fluids.

C. Decrease the infusion rate to 75 mL/hr - Lowering the infusion rate is not appropriate when a hemolytic reaction occurs; stopping the transfusion is necessary.

D. Place the client in a left lateral position - Positioning changes will not address the hemolytic reaction; stopping the transfusion and providing supportive care are the priority.

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A nurse is caring for a client following an open colectomy. Which of the following findings places the client at risk for delayed wound healing?

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