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 A
Explanation
Choice A rationale:
The goal of wound irrigation is to clean the wound, so the nurse should continue to irrigate until the drainage is clear.
Choice B rationale:
The irrigant should be at room temperature, not chilled.
Choice C rationale:
The syringe should be held 1 inch (not 0.5 inch) from the wound.
Choice D rationale:
The wound should be flushed from the cleanest area to the most contaminated, not the other way around.
Correct Answer is ["B","C","D","E"]
Explanation
E.
Choice A rationale:
Wet-to-dry dressings are not typically used for chronic wounds as they can cause tissue damage.
Choice B rationale:
Negative pressure treatment can promote healing by removing excess fluid and promoting blood flow to the wound.
Choice C rationale:
NPWT therapy, or Negative Pressure Wound Therapy, can help heal chronic wounds by removing excess fluid and promoting blood flow.
Choice D rationale:
Hydrocolloid dressings maintain a moist wound environment, which can promote healing.
Choice E rationale:
Protein is essential for wound healing as it is needed for the growth and repair of tissues.
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