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 action because the nurse should provide realistic expectations and positive reinforcement to the client. Lifestyle changes such as exercise can improve sleep quality and duration, but they may not have immediate effects. The nurse should encourage the client to continue the workout program and follow good sleep hygiene practices.

Choice B reason: This is not the best action because the nurse should focus on the client's sleep problem rather than the weight loss goal. While weight loss can be a benefit of exercise, it is not the primary reason why the client started the workout program. The nurse should not make the client feel that weight loss is the only measure of success.

Choice C reason: This is also not the best action because the nurse should not interrogate the client about the details of the exercise schedule. The nurse should respect the client's autonomy and preferences regarding physical activity. The nurse can offer suggestions or resources to help the client optimize the exercise schedule, but should not imply that the client is doing something wrong.

Choice D reason: This is another incorrect action because the nurse should not encourage the client to exercise every day or close to bedtime. Exercising too frequently or too late can interfere with the body's circadian rhythm and cause sleep problems. The nurse should advise the client to exercise at least three times a week and avoid exercising within three hours of bedtime.

A. Walks with the arms fully extended. B. Fits the crutch 2 finger widths from axilla. C. Avoids adjusting the height of the hand grips. D. Holds the crutch 6 inches (15 cm) to the side.

Correct Answer is B

Explanation

Choice A reason: This is an incorrect action as it indicates poor posture and balance. The client should walk with the elbows slightly flexed and the shoulders relaxed.

Choice B reason: This is the correct action as it ensures proper fit and comfort of the crutch. The client should fit the crutch 2 finger widths from the axilla to prevent nerve damage and pressure ulcers.

Choice C reason: This is an incorrect action as it may cause pain and injury to the wrists and hands. The client should adjust the height of the hand grips to allow a 30-degree bend at the elbow.

Choice D reason: This is an incorrect action as it may cause instability and falls. The client should hold the crutch 4 to 6 inches (10 to 15 cm) in front and to the side of the foot.

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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?

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Naxlex Comprehensive Predictor Exams

A client tells the nurse about starting an aerobic workout program to lose weight and help with insomnia. The client states that it still takes over an hour to fall asleep at night. Which action should the nurse implement?

Correct Answer is A

Explanation

The nurse is teaching a client about how to use crutches. Which action performed by the client demonstrates to the nurse a correct understanding of how to use the crutches?

Correct Answer is B

Explanation

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