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 A

Explanation

A) Severity: When the nurse asks the client to rate the pain on a scale of 0 to 10, they are assessing the severity of the pain. This component of the PQRST mnemonic focuses on understanding the intensity or severity of the pain experienced by the client. By asking the client to quantify their pain on a scale, the nurse gains insight into how much the pain is affecting the client's well-being and can use this information to guide pain management interventions.
B) Precipitating cause: This component of the PQRST mnemonic involves identifying factors that trigger or worsen the pain. Asking about activities or events that preceded the onset of pain helps the nurse understand the precipitating cause.
C) Region: This component involves identifying the specific location or region of the body where the pain is experienced. It helps the nurse localize the pain and identify potential underlying causes.
D) Quality: This component involves asking the client to describe the characteristics or quality of the pain, such as sharp, dull, stabbing, or burning. Understanding the quality of the pain provides additional information about its nature and possible underlying mechanis

A. Anxiety B. Alert C. Pacing D. Restless

Correct Answer is A

Explanation

A) Anxiety: Anxiety is a subjective finding because it represents the client's perception of their emotional state. It is a feeling of unease, worry, or fear, which the client reports experiencing. Subjective findings are based on the client's self-report or feelings.

B) Alert: Being alert is an objective finding because it refers to the client's level of consciousness and responsiveness to stimuli. In this scenario, the nurse assesses that the client is alert based on their ability to respond appropriately to questions and stimuli in the environment.

C) Pacing: Pacing is an objective finding because it describes observable behavior. In this case, the nurse observes the client pacing in the room, which is a physical activity that can be seen or measured.

D) Restless: Restlessness is an objective finding because it describes observable behavior. The nurse assesses that the client appears restless based on their observed behavior of pacing in the room. Restlessness is a physical manifestation of the client's anxiety and is observable by others.

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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

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