A nurse is caring for a client who reports a headache and has a history of a peptic ulcer. Which of the following medications should the nurse administer?

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.

The correct answer is choicea, b, e.

Choice A rationale:A recent weight gain of 1.8 kg (4 lb) with a BMI of 18.9 may indicate potential nutritional issues or underlying health problems that require further investigation.

Choice B rationale:Having an adult child prepare meals could suggest the client may have difficulties with meal preparation, possibly due to physical or cognitive limitations.

Choice C rationale:Clean and weather-appropriate clothing indicates the client is managing their personal hygiene and dressing appropriately, which does not typically prompt further assessment.

Choice D rationale:Receiving regular baths from a home care aide suggests the client has support for personal hygiene, which is generally a positive indicator and does not necessitate further assessment.

Choice E rationale:Frequent toothaches and lack of dental care can indicate poor oral health, which can have significant implications for overall health and nutrition, warranting a more detailed assessment.

Choice F rationale:Making eye contact and smiling while speaking generally indicates good social interaction skills and mental well-being, which does not typically prompt further assessment.