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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Printing electronic medical record (EMR) from backup server is not the best action to take first. It may not be possible or feasible to access the backup server if the system is down. It may also delay the communication and delivery of the prescriptions to the lab.
Choice B reason: Notifying information services department of the situation is the best action to take first. It alerts the experts who can troubleshoot and fix the problem as soon as possible. It also allows the nurse to obtain guidance on how to proceed with the documentation and prescriptions.
Choice C reason: Identifying information as late entry in the record is a relevant action to take, but not the first one. It ensures the accuracy and completeness of the EMR, but it does not address the immediate issue of the system failure. The nurse may not be able to enter the information until the system is restored.
Choice D reason: Waiting for notification that the system has been rebooted is not a proactive action to take first. It may waste valuable time and compromise the client's care. The nurse should not assume that the system will be rebooted automatically or quickly.
Correct Answer is D
Explanation
Choice A reason: This is not the most important assessment because abdominal girth is not a reliable indicator of fecal impaction. Abdominal girth can vary depending on the client's body type, fluid status, and other factors.
Choice B reason: This is also not the most important assessment because breath sounds are not directly related to fecal impaction. Breath sounds can be affected by respiratory conditions, smoking, allergies, and other factors.
Choice C reason: This is another incorrect choice because bowel sounds are not the most important assessment either. Bowel sounds can be diminished or absent in clients with fecal impaction, but they can also be altered by other gastrointestinal disorders, medications, and dietary factors.
Choice D reason: This is the correct choice because vital signs are the most important assessment prior to initiating digital removal of a fecal impaction. Vital signs can indicate the client's hemodynamic status, pain level, and risk of complications such as vagal stimulation, perforation, or infection. The nurse should monitor the client's blood pressure, pulse, respirations, and temperature before, during, and after the procedure.
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