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 B

Explanation

Choice A reason: Requesting a family member to remain with the client is not the best intervention to implement first. It may provide some emotional support, but it does not address the communication barrier. The family member may not be able to translate accurately or objectively, and may have their own biases or emotions.

Choice B reason: Obtaining a staff member who is a bilingual interpreter is the best intervention to implement first. It ensures effective communication and understanding between the nurse and the client. It also respects the client's cultural and linguistic preferences and needs.

Choice C reason: Using drawings that are universal for all cultures is not the most effective intervention to implement first. It may be helpful for some simple concepts, but it may not convey the full meaning or context of the assessment. It may also be misinterpreted or misunderstood by the client.

Choice D reason: Asking for the support of one of the client's friends is not the most appropriate intervention to implement first. It may violate the client's privacy and confidentiality, and may not ensure accurate or unbiased translation. The friend may not be familiar with the medical terminology or the client's condition.

A. Obtain the specimen from the client's current bowel movement. B. Contact the healthcare provider before obtaining the specimen. C. Withhold specimen collection until tarry black stool is observed. D. Wait to obtain the specimen until observable blood is present.

Correct Answer is A

Explanation

Choice A reason: This is the correct action because the nurse should obtain the specimen as soon as possible to avoid delays in diagnosis and treatment. The color and consistency of the stool do not affect the test for occult blood.

Choice B reason: This is not necessary because the nurse does not need to obtain a prescription or approval from the healthcare provider to collect a stool specimen for occult blood. The nurse should follow the standard protocol for specimen collection and labeling.

Choice C reason: This is incorrect because withholding specimen collection until tarry black stool is observed would delay the detection of occult blood. Tarry black stool indicates a bleeding source in the upper gastrointestinal tract, while occult blood can be present in any part of the gastrointestinal tract.

Choice D reason: This is also incorrect because waiting to obtain the specimen until observable blood is present would also delay the detection of occult blood. Observable blood indicates a bleeding source in the lower gastrointestinal tract, while occult blood can be present in any part of the gastrointestinal tract.

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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

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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