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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Contact the provider for further orders:
Contacting the provider for further orders might delay the administration of blood, which is crucial in situations where there is an urgent need, such as severe bleeding or anemia. Given that the unit of blood available is type O negative, which is universally compatible with most recipients in emergency situations, waiting for further orders could jeopardize the client's health.
B. Complete an incident report:
There is no incident or error that occurred in this situation. Using type O negative blood for a recipient with type A positive blood is an accepted practice in emergencies, and therefore, does not warrant the completion of an incident report.
C. Administer the blood as ordered:
Type O negative blood can be safely administered to recipients with any blood type in emergency situations. Since the client requires blood, and the unit available is type O negative, which is universally compatible, administering the blood as ordered is the appropriate action to ensure timely treatment.
D. Notify the blood bank:
Notifying the blood bank is unnecessary in this situation. The nurse has a unit of type O negative blood on hand, which is appropriate for immediate administration to the client with type A positive blood. There's no need to inform the blood bank as the blood is compatible and can be safely administered.
Correct Answer is B
Explanation
A. The client's daughter, who is the primary caregiver: While the daughter may be involved in the client's care and decision-making process, the client themselves should provide informed consent if they have decision-making capacity. Informed consent cannot be provided by a caregiver unless legally authorized to do so.
B. The client: The client is alert, oriented, and has advance directives. In this scenario, the client possesses decision-making capacity and is capable of providing informed consent for the procedure. As long as the client is competent and able to understand the nature, risks, benefits, and alternatives of the procedure, they are the appropriate person to sign the informed consent document.
C. The client's partner: Unless legally designated as the client's healthcare proxy or legally authorized to provide consent on the client's behalf, the partner should not sign the informed consent document. The client themselves should provide consent if they have decision-making capacity.
D. The client's son, who has a durable power of attorney: While a durable power of attorney grants legal authority to make healthcare decisions on behalf of the client if they lack decision-making capacity, it does not negate the client's ability to provide informed consent if they are competent to do so. If the client is alert, oriented, and capable of understanding the procedure, they should sign the informed consent document themselves.
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