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 B
Explanation
A) 41-year-old with hypernatremia:
Hypernatremia refers to elevated levels of sodium in the blood. While hypernatremia can lead to dehydration and electrolyte imbalances, it does not directly correlate with an increased risk of hypomagnesemia.
B) 72-year-old with chronic alcoholism:
Chronic alcoholism is a significant risk factor for hypomagnesemia. Alcohol abuse can lead to poor dietary intake of magnesium, increased renal excretion of magnesium, and impaired absorption of magnesium in the gastrointestinal tract, all contributing to magnesium deficiency.
C) 79-year-old with bone cancer:
Bone cancer does not inherently increase the risk of hypomagnesemia. However, depending on the treatment modalities and disease progression, the client may be at risk for other electrolyte imbalances or complications associated with bone cancer.
D) 46-year-old with respiratory acidosis:
Respiratory acidosis refers to an acid-base imbalance characterized by elevated levels of carbon dioxide in the blood due to impaired ventilation. While respiratory acidosis can lead to electrolyte imbalances, particularly potassium imbalances, it is not directly linked to hypomagnesemia.
Correct Answer is A
Explanation
A) Dysrhythmias:
Straining while defecating can trigger the Valsalva maneuver, which involves taking a deep breath and bearing down. This can lead to increased intrathoracic pressure, decreased venous return to the heart, and subsequently a sudden drop in blood pressure when the strain is released. These changes can cause cardiac dysrhythmias, particularly in older adults or those with underlying heart conditions.
B) Dilated pupils:
Dilated pupils are not a known consequence of straining while defecating. Pupillary dilation is typically associated with responses to low light, certain medications, or neurological conditions, rather than gastrointestinal strain.
C) Gastric ulcer:
Gastric ulcers are caused by factors such as Helicobacter pylori infection, prolonged use of nonsteroidal anti-inflammatory drugs (NSAIDs), or excessive stomach acid. Straining during defecation does not contribute to the development of gastric ulcers.
D) Diarrhea:
Straining while defecating is more likely to be associated with constipation rather than diarrhea. Diarrhea involves frequent, loose, or watery stools, whereas straining typically occurs due to hard stools and difficulty passing them.
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