The nurse is caring for a patient who has experienced a total abdominal hysterectomy. Which nursing observation of the incision will indicate the patient is experiencing a complication of wound healing?
The site is hurting.
The site has started to itch.
The site is approximated.
The site has a mass, bluish in color.
The Correct Answer is D
A: Pain at the incision site is expected after surgery and does not necessarily indicate a complication. It is important to assess the level and nature of the pain, but pain alone is not a definitive sign of a wound healing complication.
B: Itching at the incision site can be a normal part of the healing process as the wound closes and new tissue forms. While it can be uncomfortable, it is not typically a sign of a complication.
C: An approximated incision means the edges of the wound are close together and healing well. This is a positive sign and indicates that the wound is healing properly.
D: A mass, bluish in color at the incision site, may indicate a hematoma or infection, both of which are complications of wound healing. This finding requires immediate medical attention to address the underlying issue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: The client attempting to remove the restraint does not necessarily indicate a need to loosen it. The nurse should assess the reason for the client’s behavior.
B: The client’s hand being cold and pale indicates compromised circulation, which requires immediate loosening of the restraint to restore blood flow.
C: Full range of motion in the wrist suggests that the restraint is not too tight and does not need to be loosened.
D: A capillary refill of less than 2 seconds indicates good circulation, so the restraint does not need to be loosened.
Correct Answer is B
Explanation
A: A nasal cannula delivers a lower concentration of oxygen, typically between 24-44% FIO2, and is used at flow rates of 1-6 L/min. It is not suitable for delivering 40-60% FIO2.
B: A simple face mask can deliver 40-60% FIO2 at flow rates of 5-8 L/min. It covers the nose and mouth, providing a higher concentration of oxygen compared to a nasal cannula.
C: An aerosol mask is used for delivering humidified oxygen or medications via nebulization. It can deliver varying concentrations of oxygen but is not specifically designed for 40-60% FIO2 at 5-8 L/min.
D: A face tent is used for patients who cannot tolerate a mask, such as those with facial trauma or claustrophobia. It provides humidified oxygen but does not deliver a precise FIO2 concentration.
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