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 C
Explanation
Correct answer: C
A. Irrigate the nasogastric tube with water:
This option is not the best immediate action when a client is choking after vomiting. While irrigating the nasogastric tube with water may help clear the tube itself, it does not directly address the choking episode or potential airway obstruction. The priority in this situation is to ensure the client's airway is clear and maintain their safety.
B. Perform oropharyngeal suctioning:
While suctioning might be used later to clear the airway of secretions, it's not the first-line intervention when someone is actively choking. Suctioning can stimulate the gag reflex and worsen vomiting..
C. Elevate the head of bed 45 degrees:
The primary concern is preventing aspiration (inhaling vomit) which can lead to serious complications. Elevating the head of the bedhelps keep the head and neck in a position that promotes drainage of fluids and reduces the risk of aspiration.
D. Review the advance directive document:
Reviewing the advance directive document is important for understanding the client's wishes regarding their healthcare decisions, but it is not the appropriate action in the immediate management of a choking episode. Ensuring the client's safety and addressing the choking episode take precedence over reviewing documentation.
Correct Answer is B
Explanation
A. Encourage the use of incontinence briefs:
While incontinence briefs may help contain fecal leakage and protect clothing and bedding, they do not address the underlying issue of fecal incontinence or assist the client in achieving continence. Additionally, relying solely on incontinence briefs may not promote independence or improve the client's quality of life.
B. Assist to a bedside commode 30 minutes after meals:
This is the most appropriate intervention for establishing a bowel training regimen. Timing the use of the bedside commode after meals takes advantage of the gastrocolic reflex, which increases bowel motility after eating. Assisting the client to the commode at specific intervals helps promote regular bowel movements and may decrease the likelihood of fecal incontinence episodes.
C. Administer a glycerin suppository 15 minutes after meals:
While glycerin suppositories can stimulate bowel movements, they are typically used for acute constipation rather than chronic fecal incontinence. Additionally, using suppositories does not address the client's emotional distress or help establish a bowel training regimen focused on promoting continence.
D. Insert a rectal tube at specified intervals:
Rectal tubes are not typically used as a first-line intervention for bowel training in clients with fecal incontinence. They may be indicated in certain situations, such as severe impaction or when other interventions have failed, but they are not appropriate for all clients and may cause discomfort and complications.
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