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
A. Speak loudly and face the client:
While it's important for the nurse to speak clearly and ensure the client can see their face, speaking loudly may be perceived as patronizing or disrespectful. Many older adults may have normal hearing but prefer clear and normal volume speech.
B. Provide a very well-lit meeting space:
Ensuring adequate lighting is important for facilitating communication, especially for older adults who may have visual impairments. However, it is not as crucial as using understandable language.
C. Use everyday language when explaining issues:
This is the most important action. Using everyday language, free of medical jargon, ensures that the information is easily understood by older adult clients. Complex medical terms and terminology may be confusing or overwhelming for them, so using plain language enhances comprehension and promotes effective learning.
D. Underline key words on the written information:
This can be a helpful strategy for emphasizing important points in written materials, but it is not as critical as using everyday language when explaining concepts orally. Additionally, not all older adults may benefit from written information, as some may have visual impairments or difficulties reading. Therefore, oral communication in understandable language is paramount.
Correct Answer is C
Explanation
A. Suctions secretions from the posterior pharynx:
Suctioning secretions from the posterior pharynx is an appropriate action to maintain airway patency and prevent aspiration in an unconscious client. This action indicates proper understanding of oral care principles.
B. Tests for a gag reflex before performing oral care:
Testing for a gag reflex before performing oral care is an important safety measure, especially in unconscious clients, to prevent aspiration or airway obstruction. This action indicates proper assessment and consideration of the client's protective reflexes.
C. Places the client in a supine position:
Placing an unconscious client in a supine position during oral care can increase the risk of aspiration, as it may impair the client's ability to manage oral secretions. The preferred position for oral care in unconscious clients is typically a side-lying position to facilitate drainage of oral secretions and reduce the risk of aspiration.
D. Uses an oral airway to keep the teeth apart:
Using an oral airway to keep the teeth apart is not a standard practice for oral care in unconscious clients and may not be necessary. Proper positioning of the client's head and jaw manipulation can often provide adequate access for oral care without the need for an oral airway.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.