A nurse is caring for a postoperative patient. Which finding will alert the nurse to a potential wound dehiscence?

Chronic drainage of fluid through the incision site

Report by patient that something has given way

Drainage that is odorous and purulent

Protrusion of visceral organs through a wound opening

Answer and Explanation

The Correct Answer is B

A. Chronic drainage of fluid through the incision site:
While chronic drainage of fluid through the incision site can be a sign of wound complications, such as infection or poor wound healing, it is not as specific an indicator of impending wound dehiscence as the patient's report of "something giving way."

B. Report by patient that something has given way:
A patient reporting that something has given way is a significant indicator of potential wound dehiscence. Wound dehiscence refers to the partial or complete separation of the layers of a surgical wound, which can occur due to various factors such as poor wound healing, infection, or increased intra-abdominal pressure. Patients may describe a sensation of "something giving way" or "popping" if the wound starts to separate.

C. Drainage that is odorous and purulent:
Odorous and purulent drainage from an incision site may indicate an infection, which can contribute to wound dehiscence. However, this finding alone may not necessarily indicate immediate wound dehiscence.

D. Protrusion of visceral organs through a wound opening:
Protrusion of visceral organs through a wound opening is a severe complication known as evisceration, which is the most advanced stage of wound dehiscence. While this finding is indicative of a significant wound complication, it typically occurs after the initial separation of wound layers. Therefore, it is not an early sign that would alert the nurse to potential wound dehiscence

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

A) Halitosis: Halitosis refers to bad breath, which may or may not be related to bruxism. While teeth grinding can contribute to dental issues that may lead to halitosis, it is not the primary disorder associated with teeth grinding.
B) Sordes: Sordes refers to the accumulation of foul-smelling crusts or deposits around the teeth and gums, typically seen in individuals with poor oral hygiene or compromised oral health. It is not directly related to teeth grinding.
C) Bruxism: Bruxism refers to the habit of grinding or clenching the teeth, especially during sleep. It can lead to dental problems, jaw pain, headaches, and other issues related to the temporomandibular joint (TMJ). Referring the client to a dentist for evaluation and management of bruxism is appropriate to address the underlying dental concerns associated with teeth grinding.
D) Xerostomia: Xerostomia, also known as dry mouth, is a condition characterized by reduced saliva production. While xerostomia may exacerbate dental problems and contribute to oral discomfort, it is not specifically associated with teeth grinding.

A. Calcium gluconate 1.5 grams IV now B. Dextrose 50% injection (50ml) IV push now C. Colace 100 mg PO now D. Regular insulin 10 units IV now E. Potassium chloride 20 mEq orally now

Correct Answer is ["A","B","D"]

Explanation

A) Calcium gluconate 1.5 grams IV now: Calcium gluconate is administered to counteract the effects of hyperkalemia by stabilizing the myocardial cell membrane. It does not lower potassium levels but helps protect the heart from potential dysrhythmias associated with high potassium levels.

B) Dextrose 50% injection (50ml) IV push now: Dextrose 50% injection, also known as D50W, is administered to temporarily shift potassium from the extracellular space into the intracellular space, thereby lowering serum potassium levels. It is commonly used in combination with insulin to facilitate the movement of potassium into cells.

C) Colace 100 mg PO now: Colace is a stool softener and does not affect serum potassium levels. It is not indicated for the treatment of hyperkalemia.

D) Regular insulin 10 units IV now: Regular insulin is administered with dextrose to facilitate the movement of potassium from the extracellular space into the intracellular space. Insulin stimulates the cellular uptake of glucose, which in turn drives potassium into cells along with glucose.

E) Potassium chloride 20 mEq orally now: Potassium chloride is contraindicated in the treatment of hyperkalemia as it would further increase serum potassium levels. It is typically used to supplement potassium in clients with hypokalemia, not hyperkalemia.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a postoperative patient. Which finding will alert the nurse to a potential wound dehiscence?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client tells the nurse that he suspects that he grinds his teeth at night. The nurse should explain that the client should see a dentist for this problem, which she should document as which of the following disorders?

Correct Answer is C

Explanation

The nurse is caring for the client with cardiac and renal disease. The client now has a serum potassium level of 6.0 mEq/L. Which medications, if prescribed, should the nurse administer? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

A nurse is caring for a client who has advanced lung cancer. The client's provider has recommended hospice services for the client. Which of the following statements by the client indicates a correct understanding of hospice care?

A nurse is teaching a class about the use of pain medications for clients who have an opioid addiction. Which of the following medications are a nonopioid analgesic? (Select All that Apply)

A nurse is caring for a group of clients. Which of the following clients is eligible for hospice care? (Select All that Apply)

A nurse assesses four patients. Which patient has greatest risk for hypomagnesemia?

A nurse is assessing a client who has obstructive sleep apnea. Which of the following findings should the nurse expect?

A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following conditions?