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 B
Explanation
According to the given information, Aydan's insulin lispro (Humalog) dosage is 1 unit per 50 grams of carbohydrates eaten. As Aydan has just consumed 150 grams of carbs for lunch, we can calculate the insulin dose as follows:
Insulin dose = Carbohydrates eaten / Insulin-to-carbohydrate ratio Insulin dose = 150 grams / 50 grams/unit
Insulin dose = 3 units
Therefore, the nurse should prepare to administer 3 units of Aydan's prescribed rapid-acting insulin (Insulin lispro) to cover the carbohydrates he consumed for lunch. The long-acting insulin (Glargine) is typically given at bedtime to provide a basal insulin level and is not directly related to meal coverage.
Correct Answer is A
Explanation
After spinal fusion surgery, it is important to limit the patient's activity and movement to allow for proper healing and to prevent complications. The order to have the patient out of bed three times daily and ad lib (as desired) is not appropriate immediately after surgery.
The other orders listed are appropriate for the postoperative care of a patient who has undergone spinal fusion surgery:
- Assess neurological status every 4 hours: This is important to monitor for any changes in neurological function, which could indicate complications such as nerve damage or spinal cord compression.
- Logroll only to change position: Logrolling is a technique used to move patients with spinal fusion surgery while keeping their spine aligned and minimizing stress on the surgical site. This order is appropriate to ensure proper positioning and prevent injury to the surgical area.
- Monitor vital signs every 4 hours: Monitoring vital signs helps to assess the patient's overall condition and detect any signs of complications such as bleeding or infection.
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