The nurse is alert to the indication of possible dehiscence of an abdominal surgical wound, which would be evidenced by:
Increased pallor of the surgical site.
Increased serosanguineous drainage from the wound.
Excessive gas.
Complaint of constipation.
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
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.
Correct Answer is ["A","C","D"]
Explanation
E.
Choice A rationale:
Proper nutrition with adequate protein and vitamin C is essential for wound healing as these nutrients are needed for collagen synthesis.
Choice B rationale:
Resting as much as possible and keeping the incisional area still may not necessarily aid in healing. Movement can actually promote circulation and healing.
Choice C rationale:
Increasing fluid intake to at least 4000 mL per day can help keep the body hydrated, which is beneficial for wound healing.
Choice D rationale:
Keeping skin and surrounding tissue clean and dry can help prevent infection, which can delay wound healing.
Choice E rationale:
Exercise and deep breathing can increase oxygenation, which is beneficial for wound healing.
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