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.
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.
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A, apply a motion sensor mat to the client's bed. This is an effective intervention to monitor the client's movements and prevent falls. The mat is placed under the bed sheet and will sound an alarm if the client tries to get out of bed.
- Moving the overbed table away from the bed is not the correct answer because it does not prevent falls.
- Raising all four side rails while the client is in bed is not the correct answer because it can cause the client to feel trapped and can lead to injuries if they try to climb over the rails.
- Leaving the television on in the client's room is not the correct answer because it can be distracting and interfere with the client's sleep.
Correct Answer is B
Explanation
"Sitting quietly near the bedside can provide comfort and support." The nurse's response should provide appropriate comfort and support to the dying client's family, and sitting quietly near the bedside can provide just that.
Options A, C, and D are incorrect because medicating the client to wake them up or to minimize drowsiness is not appropriate as it interferes
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