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 A
Explanation
Choice A reason: This is the correct action as it prevents the risk of spillage, scalding, or infection. The basin of water should not be placed on the bed, but on a bedside table or stand. The nurse should also check the temperature of the water and the condition of the client's foot.
Choice B reason: This is an incorrect action as it may cause irritation or allergic reaction. The skin cream should not be added to the basin of water, but applied after the foot is dried and inspected. The nurse should also verify the type and amount of skin cream to be used.
Choice C reason: This is an important action, but not the priority. The UAP should dry between the client's toes completely to prevent fungal growth or maceration. The nurse should also monitor the UAP's technique and provide feedback.
Choice D reason: This is an inaccurate statement. The procedure of soaking the client's foot in a basin of warm water is not damaging to the skin, if done properly and safely. The nurse should explain the rationale and benefits of the procedure to the UAP.
Correct Answer is A
Explanation
Choice a reason: A 3 mL syringe is the most accurate device for measuring a 2 mL dose of a viscous liquid solution due to its design and gradation precision. Syringes provide clearly marked measurement lines, allowing for highly accurate dosing, especially for amounts as small as 2 mL. For viscous liquids, the controlled plunger mechanism of a syringe ensures smooth and consistent measurement and delivery. This is critical in nursing practice, as even slight deviations in medication dosing can lead to therapeutic failures or adverse effects. Additionally, syringes are designed to handle a variety of liquid viscosities, reducing the likelihood of measurement errors caused by sticking or uneven flow. By eliminating the need for visual estimation common with other tools, the syringe minimizes user error and enhances patient safety. The 3 mL capacity ensures the nurse can measure the exact dose without overloading or underutilizing the equipment, maintaining both precision and ease of use.
Choice b reason: A one-ounce medicine cup is less accurate for measuring a 2 mL dose due to its relatively larger size and less precise measurement gradations. Medicine cups are typically designed for measuring larger volumes, such as 5 mL, 15 mL, or more, and are not ideal for small doses. The wide surface area and less detailed markings make it difficult to accurately align the liquid level to the desired measurement, especially for small amounts like 2 mL. This can result in over- or under-dosing, which is particularly problematic when administering potent medications. Additionally, the open design of medicine cups may make pouring viscous liquids challenging, as the liquid may stick to the sides of the cup, leading to further inaccuracies. While convenient for larger doses or liquid mixtures, the medicine cup does not offer the precision required for small, specific dosages in clinical practice.
Choice c reason: A tuberculin syringe, which has a capacity of 1 mL, is specifically designed for administering very small doses, such as subcutaneous or intradermal injections. Using it for a 2 mL dose is impractical and could lead to dosing errors. The nurse would need to fill the syringe twice to administer the full 2 mL, increasing the risk of cumulative measurement inaccuracies. This approach is also time-consuming and may lead to wastage of the medication, as viscous liquids can leave residue inside the syringe, further complicating the dose calculation. Additionally, the markings on a tuberculin syringe are optimized for fractions of a milliliter, not for whole milliliter increments, making it unsuitable for measuring a 2 mL dose. Using this tool for a dose beyond its designed capacity contradicts best practices in nursing, which emphasize using equipment tailored to the specific requirements of the medication and patient.
Choice d reason: Using a 3 mL syringe with a sterile needle is unnecessary and not recommended for administering an oral medication. While the 3 mL syringe itself is suitable for measuring a 2 mL dose, the inclusion of a sterile needle is irrelevant and introduces an additional risk of improper administration. Oral medications are not meant to be injected, and the presence of a needle could lead to accidental use or injury. Furthermore, sterile needles are specifically intended for invasive procedures, such as intramuscular or intravenous injections, and their inclusion in an oral medication protocol is not only superfluous but also contraindicated. The presence of the needle complicates the preparation process without providing any benefit, detracting from the simplicity and efficiency of administering the medication orally. In nursing practice, ensuring that the equipment matches the route of administration is crucial to patient safety and protocol adherence.
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