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

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Correct Answer is B

Explanation

A) "The health care proxy does not go into effect until I am incapable of making decisions.": This statement is accurate. A health care proxy, also known as a durable power of attorney for health care or health care agent, is appointed to make medical decisions on behalf of the client if they become unable to do so themselves. This can include decisions related to treatment options, end-of-life care, and other medical interventions.

B) "I have to choose a family member as my health proxy.": This statement is incorrect. While some individuals may choose a family member as their health care proxy, it is not a requirement. The client can choose any competent adult who is willing to serve as their health care proxy, including a friend, relative, or even a legal representative.

C) "If I become incapacitated, end-of-life choices will be made by my proxy.": This statement is accurate. The health care proxy is responsible for making medical decisions on behalf of the client if they are unable to do so, including decisions related to end-of-life care and treatment preferences.

D) "I can change who I designate as my health care proxy at any time.": This statement is accurate. The client has the right to change their health care proxy at any time by completing a new advance directive document and revoking any previous designations. It is essential for the client to review and update their advance directives regularly to ensure they reflect their current wishes and preferences.

A. "I will have to be admitted to a long-term care in order to receive hospice care" B. "My oncologist will continue to look for a cure for my cancer while am receiving hospice care" C. "I should expect the hospice team to help me manage my dyes" D. "Hospice care services are available to patients who are terminally regardless of their life E. expectancy"

Correct Answer is C

Explanation

Answer: C. "I should expect the hospice team to help me manage my dyes."

A. "I will have to be admitted to a long-term care facility in order to receive hospice care."
This statement reflects a misunderstanding of hospice care. Hospice services can be provided in various settings, including the client’s home, hospice centers, or even long-term care facilities, but clients are not required to be admitted to a long-term care facility specifically to receive hospice care.

B. "My oncologist will continue to look for a cure for my cancer while I am receiving hospice care."
Hospice care focuses on comfort and quality of life for clients with terminal illnesses, rather than curative treatment. Clients receiving hospice care have typically decided to forego curative treatment to prioritize symptom management and palliative care.

C. "I should expect the hospice team to help me manage my dyes."
This statement indicates an understanding of hospice care. The hospice team provides comprehensive support to manage symptoms, such as pain and discomfort, as well as addressing emotional, spiritual, and psychosocial needs. The goal is to ensure the client’s comfort during the end of life.

D. "Hospice care services are available to patients who are terminally ill regardless of their life expectancy."
This is not entirely accurate. Hospice care is typically available to individuals who have a life expectancy of six months or less, as determined by their healthcare provider. Therefore, life expectancy is an important criterion for hospice eligibility.

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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 nurse is caring for a client who has named a person to serve as his health care proxy. The client states he needs clarification about this type of advance directives. Which of the following statements by the client indicates a need for clarification?

Correct Answer is B

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?

Correct Answer is C

Explanation

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