The nurse clarifies that a vacuum-assisted closure supports healing of a wound by:

Choice A rationale:

Increased pallor of the surgical site is not a typical sign of wound dehiscence. It could indicate poor blood flow to the area, but it’s not directly related to dehiscence.

Choice B rationale:

Increased serosanguineous drainage from the wound is a common sign of wound dehiscence. This type of drainage is a mixture of blood and serum, and an increase could indicate that the wound edges are separating.

Choice C rationale:

Excessive gas is not a typical sign of wound dehiscence. It could be related to other postoperative complications, such as ileus or bowel obstruction, but not specifically to dehiscence.

Choice D rationale:

Complaint of constipation is not a typical sign of wound dehiscence. It could be related to other postoperative complications, such as side effects of pain medication or decreased mobility, but not specifically to dehiscence.

E.

Choice A rationale:

A BMI of 20 is within the normal range (18.5-24.9), so it does not increase the risk of a pressure injury.

Choice B rationale:

Peripheral neuropathy can lead to a loss of sensation, which increases the risk of a pressure injury as the individual may not feel discomfort or recognize the need to reposition.

Choice C rationale:

Immobility is a major risk factor for pressure injuries as it increases pressure on certain areas of the body, reducing blood flow and leading to tissue damage.

Choice D rationale:

Hypoperfusion, or reduced blood flow, can lead to tissue hypoxia and increase the risk of pressure injuries.

Choice E rationale:

A prealbumin level of 16 mg/dL is at the lower end of the normal range (15-36 mg/dL)2. Low prealbumin levels can indicate poor nutritional status, which is a risk factor for pressure injuries.