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 B

Explanation

This ABG result indicates that the client has an excess of carbon dioxide (CO2) due to hypoventilation.

A. "Metabolic acidosis" is an incorrect answer because the pH is low and the HCO3 is within normal range.

C. "Respiratory alkalosis" is an incorrect answer because the pH is low and the PaCO2 is elevated.

D. "Metabolic alkalosis" is an incorrect answer because the HCO3 is within normal range, and the pH is low.

Explanation: The ABG result shows a low pH, elevated PaCO2, and normal HCO3, indicating respiratory acidosis. This condition can be caused by conditions that affect breathing, such as pneumonia, asthma, or chronic obstructive pulmonary disease (COPD).

A. Obtain a set of vital signs. B. Flex the client's knees and hips. C. Apply a moist saline dressing to the area. D. Elevate the head of the client's bed 20°.

Correct Answer is C

Explanation

The correct answer is c. Apply a moist saline dressing to the area.

Choice A reason: Obtaining a set of vital signs is important, but it is not the immediate priority in this situation. The vital signs will not address the protruding organs directly.

Choice B reason: Flexing the client’s knees and hips may provide comfort but does not directly address the issue of the open incision and protruding organs.

Choice C reason: Applying a moist saline dressing to the area is the correct action. It helps to protect the protruding organs by keeping them moist and reduces the risk of organ damage or infection. This is the priority action to keep the organs moist and reduce the risk of tissue damage until surgical repair can be done.

Choice D reason: Elevating the head of the client’s bed 20° may be part of the overall care plan, but it is not the immediate priority when dealing with protruding organs from an open abdominal incision.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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