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: Chewing sublingual medication is incorrect. Sublingual medications are designed to dissolve under the tongue for rapid absorption into the bloodstream.
B: Letting the medication dissolve completely is correct. This ensures that the medication is absorbed properly and works effectively.
C: There is no restriction on drinking juice with sublingual medication unless specified by the healthcare provider. This statement does not indicate a clear understanding of sublingual administration.
D: Placing the medication between the cheek and gum is incorrect for sublingual medications. This method is used for buccal medications, not sublingual ones.
Correct Answer is C
Explanation
A: Hyperkalemia refers to high potassium levels, which can occur in ESKD but does not directly cause shortness of breath, swelling, or crackles in the lungs.
B: Hyponatremia refers to low sodium levels, which can occur in ESKD but does not directly cause the symptoms described.
C: Hypervolemia, or fluid overload, is the most likely cause of the client’s symptoms. ESKD can lead to fluid retention, causing shortness of breath, swelling, crackles in the lungs, and elevated blood pressure.
D: Hypovolemia refers to low blood volume, which would not cause the symptoms of fluid overload described in the client.
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