A nurse is reviewing the medical record of a client who had abdominal surgery 2 days ago. The nurse should identify that which of the following findings indicates the client is at risk for delayed wound healing?
Oxygen saturation 97% on room air
Pain level of 1 on a scale of 0 to 10
BMI 35
Capillary refill time 1 second
The Correct Answer is C
Rationale:
A. Oxygen saturation 97% on room air: Adequate oxygenation is essential for wound healing because oxygen supports collagen synthesis and tissue repair. An oxygen saturation of 97% indicates sufficient oxygen delivery to tissues and does not place the client at risk for delayed healing.
B. Pain level of 1 on a scale of 0 to 10: Minimal pain suggests effective postoperative pain management and allows the client to move, breathe deeply, and participate in recovery activities. Pain at this level does not negatively impact the wound-healing process.
C. BMI 35: Obesity is associated with delayed wound healing due to poor vascularity in adipose tissue, which reduces oxygen and nutrient delivery to the wound. Increased tension on wound edges and a higher risk of infection also contribute to impaired healing in obese clients.
D. Capillary refill time 1 second: A capillary refill of 1 second reflects adequate peripheral perfusion, which supports effective oxygen and nutrient delivery to tissues. Normal circulation facilitates the healing process rather than delaying it.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Ensure each individual can respond defensively about the conflict: Encouraging defensive responses escalates tension and does not promote resolution. The goal is to facilitate understanding and collaboration, not defensiveness.
B. Use passive listening techniques during conflict resolution: Passive listening may miss key information and prevent the manager from fully understanding the concerns. Active and empathetic listening is necessary to address the conflict effectively.
C. Gather individual information regarding the conflict: Collecting perspectives from each person involved helps the nurse manager understand the root causes, identify common themes, and develop an appropriate strategy for resolution. This is a critical step in structured conflict management.
D. Ask closed-ended questions about the conflict: Closed-ended questions limit responses and do not allow individuals to fully express their concerns or feelings. Open-ended questions are more effective for exploring issues in depth.
Correct Answer is C
Explanation
Rationale:
A. "Placement of the catheter is confirmed by a CT scan.": Catheter placement is not routinely confirmed by CT scan. Instead, correct placement of a central venous catheter is verified by a chest X-ray immediately after insertion to ensure proper tip location.
B. "You will be under general anesthesia for this procedure.": General anesthesia is not required for placement of a nontunneled percutaneous central venous catheter. The procedure is typically performed using local anesthesia and aseptic technique at the bedside.
C. "The provider will wear a mask while performing the procedure.": The provider wears a mask, sterile gown, gloves, and cap as part of strict sterile technique during insertion to prevent catheter-related bloodstream infections.
D. "Your head will be elevated as high as possible while the catheter is inserted.": The client’s head is not elevated during insertion. Instead, a flat or slight Trendelenburg position is used to distend neck veins and reduce the risk of air embolism.
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