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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale:

The side-lying position allows gravity to assist in wound irrigation and prevent pooling of the solution.

Choice B rationale:

High-Fowler’s position is not ideal for abdominal wound irrigation as it can lead to pooling of the solution.

Choice C rationale:

In the supine position, the solution can pool around the wound and not effectively irrigate it.

Choice D rationale:

The dorsal recumbent position is not ideal as it can also lead to pooling of the solution.

A. Purulent. B. Serous. C. Sanguinous. D. Serosanguineous.

Correct Answer is D

Explanation

Choice A rationale:

Purulent drainage is thick and often has a foul odor. It is often a sign of infection and can have a variety of colors, including yellow, green, or brown. This is not the correct choice because the description does not match the question.

Choice B rationale:

Serous drainage is clear and watery, often seen in normal healing processes. This is not the correct choice because the description does not match the question.

Choice C rationale:

Sanguinous drainage is fresh blood, often seen in deep wounds or when a wound is disturbed. This is not the correct choice because the description does not match the question.

Choice D rationale:

Serosanguineous drainage is a mixture of blood and serous fluid, often seen in new wounds. This matches the description given in the question.

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The nurse is alert to the indication of possible dehiscence of an abdominal surgical wound, which would be evidenced by:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After closing the curtain around the client's bed, you lift his gown to expose the horizontal abdominal wound and assist the client into a comfortable position for wound irrigation.Which of the following positions is appropriate for the irrigation of his wound?

Correct Answer is A

Explanation

When changing the dressing on the patient's right arm, you see that the dressing has a moist yellow-red stain on it. You would document this as drainage.

Correct Answer is D

Explanation

The nurse is taking care of a postsurgical patient and notes the incision is clean and dry, with sutures intact.The nurse further assesses that the wound is healing by:

The nurse is alert to the indication of possible dehiscence of an abdominal surgical wound, which would be evidenced by:

A nurse is collecting data on a client.Which of the following findings increase the client's risk of a pressure injury?

The nurse places Dakin solution in a wound to accomplish chemical:

A patient who underwent removal of a breast must be discharged home with a Jackson-Pratt wound drain in place.As the patient demonstrates the procedure for emptying it, the nurse should correct her if she:

When applying an ice pack, it is necessary to:

A nurse is removing a wound dressing that is saturated with blood and purulent drainage.Which of the following methods should the nurse use when disposing of the soiled dressing?