The nurse is caring for a client one week postsurgery. Which finding should the nurse expect to see if the surgical incision is healing properly?
A well approximated Incision site.
Erythema and serosanguineous exudate.
Eschar and slough in the wound.
Beefy red granulation tissue.
The Correct Answer is A
A. A well approximated incision site:
A properly healing surgical incision typically appears well approximated, meaning the wound edges are closely aligned and held together with sutures or staples. This indicates that the wound is healing as expected and that the risk of infection and complications is minimized.
B. Erythema and serosanguineous exudate:
Erythema (redness) and serosanguineous exudate (pinkish fluid composed of serum and blood) can be normal findings in the early stages of wound healing, but they may also indicate inflammation or infection if they persist or worsen over time.
C. Eschar and slough in the wound:
Eschar (dead tissue) and slough (yellow or white necrotic tissue) are signs of tissue necrosis or delayed wound healing. They indicate that the wound is not healing properly and may require intervention such as debridement to remove dead tissue and promote healing.
D. Beefy red granulation tissue:
Beefy red granulation tissue is a sign of the proliferative phase of wound healing and indicates that the wound is healing from the bottom up. While granulation tissue is a positive sign of healing, it typically appears later in the healing process rather than one week post-surgery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The client will demonstrate ability to change the ostomy bag in two days.
This outcome statement focuses on the client's ability to perform a specific task related to ostomy care. While it's important for clients with a colostomy to learn how to change their ostomy bag, in the context of this scenario, where the client has developed hyperglycemia requiring insulin injections, the priority lies in managing their diabetes and adhering to the medication regimen. Therefore, while ostomy care is important, it may not be the most immediate concern.
B. The client will adhere to the medication regimen after discharge.
This outcome statement directly addresses the client's need to manage their hyperglycemia by adhering to the prescribed insulin regimen. Given that the client has developed hyperglycemia requiring insulin injections, ensuring medication adherence is crucial for controlling blood sugar levels and preventing complications associated with uncontrolled diabetes. This choice aligns with the client's health needs and goals following the surgical procedure and the development of hyperglycemia.
C. The client's breath sounds will be auscultated by the nurse every 4 hours.
This outcome statement focuses on monitoring the client's respiratory status by auscultating breath sounds at regular intervals. While respiratory assessment is important, especially postoperatively, it may not directly address the client's primary health concern in this scenario, which is managing hyperglycemia and insulin administration.
D. The client attempts to self-administer insulin but is unable to perform injection.
This outcome statement indicates the client's attempt to self-administer insulin but inability to perform the injection. While it's important for clients to be able to self-administer insulin, the emphasis in this scenario should be on ensuring that the client adheres to the medication regimen, rather than focusing solely on their ability to self-administer insulin immediately after discharge. Therefore, while self-administration of insulin is relevant, it may not be the most immediate priority in the postoperative plan of care.
Correct Answer is B
Explanation
A. Observe the client's body language:
This strategy involves paying attention to the client's non-verbal cues, such as facial expressions, posture, and gestures, to gauge their level of understanding and engagement. While body language can provide valuable insights into the client's receptiveness to the information being presented, it may not always accurately reflect their comprehension or ability to recall important details. Therefore, while observing body language is beneficial, it should be supplemented with other strategies for a more comprehensive assessment of learning.
B. Ask the client for learning feedback:
This strategy involves actively soliciting feedback from the client to assess their understanding of the material presented. By asking questions such as, "Can you repeat back to me how you will take this medication?" or "Do you have any concerns or questions about the information I've provided?" the nurse can directly gauge the client's comprehension and address any areas of confusion or misunderstanding. Asking for learning feedback encourages active participation from the client and provides an opportunity for real-time clarification, making it a highly effective strategy for confirming learning.
C. Provide client-focused information:
This strategy involves tailoring the educational content to meet the specific needs, preferences, and learning styles of the client. By presenting information in a manner that resonates with the client's individual characteristics and circumstances, such as using plain language, visual aids, or culturally sensitive materials, the nurse can enhance the client's understanding and retention of the material. Providing client-focused information fosters a more personalized and relevant learning experience, which can contribute to better outcomes and adherence to treatment recommendations.
D. Reinforce key points with the client:
This strategy involves reviewing and emphasizing important information multiple times throughout the teaching session to reinforce learning and retention. Repetition helps solidify key concepts in the client's memory and increases the likelihood of successful recall and application of the information. By revisiting key points, summarizing key concepts, and providing opportunities for practice or self-assessment, the nurse can help reinforce the client's understanding and confidence in managing their medication regimen. Reinforcing key points with the client ensures that critical information is consistently emphasized and internalized, which is essential for promoting safe and effective medication use.
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