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.

Answer and Explanation

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.

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Correct Answer is ["1"]

Explanation

To determine how many tablespoons the client should take with each dose, we need to first calculate the dosage in tablespoons based on the concentration of the oral suspension.

Given:

Dextromethorphan oral suspension concentration: 30 mg per 15 mL

To find out how many milliliters the client should take per dose:

The prescribed dose is 30 mg.

So, if 15 mL contains 30 mg, then 1 mL contains:

30 mg / 15 mL = 2 mg/mL

To find out how many milliliters the client should take for the prescribed dose:

30 mg / 2 mg/mL = 15 mL

Now, we know that the prescribed dose is 15 mL. To convert this to tablespoons, we can use the fact that 1 tablespoon (tbsp) is equal to 15 milliliters.

So, the client should take:

15 mL / 15 mL/tbsp = 1 tablespoon

Therefore, the nurse should instruct the client to take 1 tablespoon with each dose.

A. After each Instruction, ask If the client understands. B. Have an Interpreter repeat the wound care Instructions. C. Provide written instructions in the client's native language. D. Have the client demonstrate prescribed wound care.

Correct Answer is D

Explanation

A. After each instruction, ask if the client understands:

While checking for understanding after each instruction is important, it may not accurately assess the client's ability to perform wound care independently. Verbal confirmation does not ensure competency in wound care techniques.

B. Have an interpreter repeat the wound care instructions:

Having an interpreter repeat the wound care instructions may help ensure accurate communication, but it does not assess the client's ability to perform the wound care independently.

C. Provide written instructions in the client's native language:

Providing written instructions in the client's native language can be helpful for reference, but it may not effectively assess the client's understanding or ability to perform the wound care.

D. Have the client demonstrate prescribed wound care:

This is the most appropriate method for evaluating the client's understanding of self-care at home. Having the client demonstrate wound care techniques allows the nurse to directly observe the client's competency in performing the necessary tasks. It provides a practical assessment of the client's ability to independently manage wound care post-discharge. If the client is unable to demonstrate the procedure correctly, the nurse can provide additional education and support as needed.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receives a prescription for dextromethorphan 30 mg every 6 to 8 hours PO as needed for cough. The bottle is labeled "Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL." How many tablespoons should the nurse instruct the client to take with each dose? (Enter numerical value only.)

Correct Answer is ["1"]

Explanation

A client who had emergency gallbladder surgery yesterday is getting ready for discharge. The client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client's understanding of self care at home?

Correct Answer is D

Explanation

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