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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "My stoma size will stay the same, even after it has healed." - This statement is incorrect.
Stoma size can change during the healing process and may continue to evolve over time due to factors such as swelling, retraction, or prolapse.
B. "My stoma will drain liquid fluid continuously." - This statement is correct. In an ileostomy, the stoma typically drains liquid stool continuously due to the absence of the colon, which is responsible for absorbing water from the feces.
C. "I will change my pouch system every 2 weeks." - This statement is incorrect. The frequency of pouch changes depends on individual factors such as stoma size, type of pouching system used, and personal preference. It is essential to teach clients to change their pouch when needed, which may vary from a few days to a week or longer.
D. "I will ensure that my medications are enteric coated." - This statement is unrelated to ileostomy care. Enteric-coated medications are designed to resist dissolution in the acidic environment of the stomach and instead dissolve in the alkaline environment of the small intestine. It is not directly relevant to stoma care.
Correct Answer is B
Explanation
A. Serum calcium levels are not directly indicative of hypervolemia.
B. A urine specific gravity of 1.001 indicates dilute urine, which is a common finding in hypervolemia as the kidneys attempt to excrete excess fluid.
C. Serum sodium levels within the normal range (e.g., 138 mEq/L) are not indicative of hypervolemia.
D. Urine pH of 6.1 is within the normal range and does not specifically indicate hypervolemia.
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