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 A
Explanation
Glipizide is an oral antidiabetic medication commonly prescribed to manage type 2 diabetes. It works by stimulating the release of insulin from the pancreas, which helps lower blood glucose levels. However, there is a risk of hypoglycemia (low blood sugar) with the use of Glipizide.
It is crucial for the client to be aware of the signs and symptoms of hypoglycemia so that they can take appropriate action if their blood sugar drops too low. These symptoms may include sweating, trembling, dizziness, confusion, weakness, and hunger. By recognizing these signs, the client can promptly address hypoglycemia by consuming a source of fast-acting glucose, such as fruit juice or glucose tablets, as instructed by their healthcare provider.
Correct Answer is C
Explanation
Morphine is a potent opioid analgesic that can depress the respiratory system. Respiratory depression is a potential adverse effect of morphine, and it is essential for the nurse to monitor the patient's respiratory rate regularly to ensure adequate oxygenation and prevent respiratory complications.
By checking the respiratory rate, the nurse can assess if the patient is breathing adequately and detect any signs of respiratory depression. If the respiratory rate is significantly decreased or the patient shows signs of respiratory distress (e.g., shallow or irregular breathing), immediate intervention is necessary to address the situation promptly.
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