A nurse is examining the abdominal wound of a client who is 3 days postoperative following a hemicolectomy. Which of the following findings indicates a wound infection?

Redness around the incision line

Bruising around the wound

Serous wound drainage

Crusting along the incision.

Answer and Explanation

The Correct Answer is A

Redness around the incision line. Redness around the incision line indicates inflammation and is a sign of wound infection. Bruising around the wound and crusting along the incision are normal findings in the early postoperative period. Serous wound drainage is a normal finding after surgery and is not an indication of infection.

Other choices are not correct because:

B. Bruising around the wound: This is a normal finding in the early postoperative period.

C. Serous wound drainage: This is a normal finding after surgery and is not an indication of infection.

D. Crustin

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Correct Answer is A

Explanation

Elevate the head of the client's bed for 1 hr after the feeding. This is because elevating the head of the client's bed to at least 30 degrees can help prevent aspiration and gastric reflux.

Choice B is incorrect because administering the feeding solution at a cold temperature can cause discomfort and diarrhea.

Choice C is incorrect because rotating the jejunostomy tube once per day can cause irritation and trauma to the stoma site.

Choice D is incorrect because flushing the tube with 90 mL of sterile water before and after the feeding is not necessary as long as the tube is adequately flushed before and after each feeding.

The explanation for why the other choices are not answered: B – Administering the feeding solution at a cold temperature can cause discomfort and diarrhea, so it should not be done. C – Rotating the jejunostomy tube once per day can cause irritation and trauma to the stoma site, so this is not the correct action. D – Flushing the tube with 90 mL of sterile water before and after the feeding is unnecessary to do as long as the tube is adequately flushed before and after each feeding. Thus, this is not the correct answer.

A. Oropharyngeal airway B. Water-soluble lubricant C. Yankauer catheter D. Sterile gloves E. Sterile gloves

Correct Answer is C

Explanation

Yankauer catheter. A Yankauer catheter is a suction device used for oral suctioning. It is important for this client to have access to a Yankauer catheter for safe and effective suctioning of secretions from the mouth.

Option A is incorrect because an Oropharyngeal airway is used to maintain or open the airway.

Option B is incorrect because the water-soluble lubricant is used for lubricating the suction catheter during suctioning.

Option D is incorrect because sterile gloves are not routinely needed for suctioning.

Reasons why the other options are not answered: Option A: An oropharyngeal airway is not used for suctioning but is used to maintain an open airway in an unconscious patient. Option B: Water-soluble lubricant is used for lubricating the suction catheter during suctioning. Option D: Sterile gloves are not routinely needed for suctioning.

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A nurse is examining the abdominal wound of a client who is 3 days postoperative following a hemicolectomy. Which of the following findings indicates a wound infection?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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