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
Monitor for at least 150 mL of drainage every hour. The nurse should monitor the chest tube drainage for excessive or sudden increases in order to detect any complications, such as pneumothorax. Clamping the tube for 30 minutes every 8 hours is not standard practice and can cause complications. Pinning the tubing to the client's bed sheets can cause traction on the chest tube and should be avoided. The chest tube unit should only be replaced when there is a problem with the unit or the seals.
Choice B: Clamping the tube for 30 minutes every 8 hours is not standard practice and can cause complications.
Choice C: Pinning the tubing to the client's bed sheets can cause traction on the chest tube and should be avoided.
Choice D: The chest tube unit should only be replaced when there is a problem with the unit or the seals.
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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