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.
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Related Questions
Correct Answer is D
Explanation
Nausea and vomiting can lead to excessive loss of fluids and electrolytes, including potassium, from the body. Gastroenteritis is an inflammation of the gastrointestinal tract typically caused by viral or bacterial infections. It is commonly characterized by symptoms such as diarrhea, vomiting, abdominal pain, and fever. Antibiotics are not typically used to treat viral gastroenteritis and would not directly cause the electrolyte imbalance. Administration of IV Furosemide, a diuretic, would increase urine output but is not typically used to treat gastroenteritis. The fever itself may contribute to fluid loss but would not directly cause the electrolyte imbalance.
Correct Answer is A
Explanation
In a client with minimal change nephrotic syndrome (MCNS), the primary concern is the management of fluid volume and hydration status. MCNS is characterized by increased glomerular permeability, leading to excessive protein loss in the urine and subsequent hypoalbuminemia. This can result in fluid retention and edema formation, including facial edema.
Hypertension is a common complication in clients with MCNS, and it further contributes to fluid retention and potential complications. Therefore, closely monitoring the client's fluid volume and hydration status, including daily weights, intake and output measurements, and assessment of edema, is crucial to detect any changes and guide appropriate interventions.
While other actions, such as consulting with a registered dietitian about adequate intake or using sterile technique to prevent infections, may be important aspects of the client's care, they are not the priority in this situation. The immediate concern is managing the client's hypertension and fluid volume status to prevent complications associated with MCNS.
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