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.
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This response indicates that the client understands that sudden jaw pain can be a sign of a heart attack and requires immediate medical attention.
A. "I will take four nitroglycerin sublingual tablets if I have chest pain." This is an incorrect statement because taking four nitroglycerin sublingual tablets can lead to hypotension and can be life-threatening.
B. "I will have hot, dry, and flushed skin if I am having a heart attack." This is an incorrect statement because hot, dry, and flushed skin is not a typical sign of a heart attack.
C. "I will wait 30 minutes before taking action if I have heartburn." This is an incorrect statement because heartburn is not a symptom of angina and waiting 30 minutes to take action can lead to further complications.
Explanation: The client with angina should be educated about the signs and symptoms of a heart attack and when to seek medical attention. Jaw pain is one of the signs of a heart attack, and the client should seek emergency medical attention immediately.
Correct Answer is B
Explanation
The correct answer is choice B: Store opened insulin vials at room temperature for up to 4 weeks.
Choice B rationale: Opened insulin vials can be stored at room temperature (59°F to 86°F or 15°C to 30°C) for up to 4 weeks. After this period, the insulin may lose potency, and a new vial should be used.
Choice A rationale: Regular insulin is short-acting, and its peak effect occurs 2 to 3 hours after administration. Eating a snack 6 hours after insulin administration may not be necessary as the insulin would have already reached its peak effect, and blood glucose levels should be monitored accordingly.
Choice C rationale: Warming the insulin vial to dissolve crystals is not recommended. Insulin should be inspected before use, and if crystals or clumps are present, it should be discarded as this could indicate that the insulin has lost its effectiveness.
Choice D rationale: Unopened insulin vials should be stored in the refrigerator (36°F to 46°F or 2°C to 8°C) and should not be frozen. Freezing can cause insulin to lose potency or become ineffective. Once opened, insulin vials can be stored at room temperature for up to 4 weeks, as mentioned in choice B.
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