The nurse is assessing a patient's postoperative wound and finds it has separated from the suture line with extrusion of the intestine through the opening. How does the nurse document this finding?
Wound evisceration
Wound dehiscence
Wound infection
Wound tunneling
The Correct Answer is A
Wound evisceration refers to the protrusion of internal organs or tissues through an open wound. In this case, with the separation of the wound and extrusion of the intestine through the opening, it is a clear indication of wound evisceration. It is a surgical emergency that requires immediate medical attention.
Wound dehiscence, on the other hand, refers to the separation or opening of a previously closed surgical incision or wound. It does not involve the extrusion of internal organs or tissues.
Wound infection refers to the presence of infectious microorganisms in the wound, leading to inflammation and other signs of infection.
Wound tunneling refers to the formation of narrow channels or tunnels within the wound, often caused by improper wound healing or infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Prednisone is a corticosteroid medication that can increase blood glucose levels by promoting gluconeogenesis (the production of glucose from non-carbohydrate sources) and reducing glucose utilization in the body. This can lead to elevated blood sugar levels, especially in individuals with diabetes. The client's history of urinary tract infection and the use of Prednisone suggest that the infection might have triggered the development of DKA.
It's important to note that DKA can occur even when a person is taking insulin as prescribed and following their diet carefully if other factors contribute to the development of DKA, such as an underlying infection or the use of certain medications like Prednisone. The nurse should further assess the client's condition and notify the healthcare provider to initiate appropriate management for DKA.
Correct Answer is C
Explanation
Pin site care is essential to prevent infections and other complications associated with external fixation devices. The nurse should instruct the patient to clean the pin insertion sites daily with a sterile saline solution or as per healthcare provider's instructions. The patient should also observe for signs of infection, such as redness, swelling, warmth, and drainage, and report any concerns to the healthcare provider.
Assessing the skin under the foam boot twice daily is not specific to external fixation devices, and it may not be relevant to this patient's care plan. The nurse should focus on teaching the patient about external fixation device care specifically.
Taking prophylactic antibiotics before any dental work for the rest of your life is not relevant to external fixation devices or right lower leg fractures. It is a recommendation for patients with certain heart conditions who may be at risk of developing infective endocarditis during dental procedures.
Removing the external fixator for the shower is not recommended as the device should be kept dry to prevent infections. The nurse should instruct the patient to cover the device with a waterproof dressing or plastic bag during showering to protect it from getting wet.
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