The nurse is caring for a client one week post-surgery. Which finding should the nurse expect to see if the surgical incision is healing properly?

Eschar and slough in the wound.

A well-approximated incision site.

Beefy red granulation tissue.

Erythema and serosanguineous exudate.

Answer and Explanation

The Correct Answer is B

Choice A reason: Eschar and slough in the wound are not signs of proper healing. They are necrotic tissue that impairs wound healing and increases the risk of infection. They should be removed by debridement to promote wound closure.

Choice B reason: A well-approximated incision site is a sign of proper healing. It means that the edges of the wound are close together and aligned, without gaps or separation. It indicates that the wound is healing by primary intention, which is the fastest and most desirable method of wound healing.

Choice C reason: Beefy red granulation tissue is a sign of healing, but not of proper healing for a surgical incision. It is new tissue that fills the wound bed and consists of blood vessels and connective tissue. It indicates that the wound is healing by secondary intention, which is a slower and less desirable method of wound healing.

Choice D reason: Erythema and serosanguineous exudate are not signs of proper healing. They are signs of inflammation and possible infection. Erythema is redness of the skin around the wound, and serosanguineous exudate is a mixture of blood and serum that drains from the wound. They should be monitored and reported to the health care provider.

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Correct Answer is A

Explanation

Choice A reason: This is the correct instruction as it ensures that the injection is given in a well-perfused area with minimal risk of injury to major blood vessels or organs. The umbilicus should be avoided as it may harbor bacteria or cause discomfort.

Choice B reason: This is an incorrect instruction as it may result in a loss of medication or inaccurate dosing. The air bubble in the prefilled syringe should be left intact as it helps to seal the medication in the subcutaneous tissue and prevent leakage.

Choice C reason: This is an incorrect instruction as it may cause irritation or inflammation of the injection sites. The gluteal area should be avoided as it has a higher risk of hitting a nerve or blood vessel. The abdomen is the preferred site for low-molecular-weight heparin injections.

Choice D reason: This is an incorrect instruction as it may increase the risk of bleeding or bruising. The injection site should not be massaged or rubbed as it may dislodge the clot or damage the tissue.

A. Encourage the client to focus on taking deep breaths. B. Tell the client the medication needs more time to work. C. Ask the UAP to offer a backrub to the client. D. Reassess the client and the level of pain.

Correct Answer is D

Explanation

Choice A reason: This is not the best intervention as it does not address the cause of the pain or provide adequate relief. Deep breathing may help the client to relax and cope with the pain, but it is not enough to manage severe pain.

Choice B reason: This is not a true or helpful statement as it may imply that the nurse is dismissing the client's pain or delaying further action. Oxycodone is a fast-acting opioid analgesic that reaches its peak effect within 30 to 60 minutes. If the client is still in severe pain after one hour, the nurse should reassess the pain and notify the healthcare provider.

Choice C reason: This is not the priority intervention as it does not address the cause of the pain or provide adequate relief. A backrub may help the client to relax and distract from the pain, but it is not enough to manage severe pain.

Choice D reason: This is the best intervention as it helps the nurse to evaluate the effectiveness of the medication and the need for further intervention. The nurse should use a valid and reliable pain assessment tool and ask the client about the location, intensity, quality, and duration of the pain. The nurse should also check the client's vital signs and observe for any signs of adverse effects from the medication.

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The nurse is caring for a client one week post-surgery. Which finding should the nurse expect to see if the surgical incision is healing properly?

Nursing Test Bank

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