Which finding will alert the nurse to a potential wound dehiscence?
Report by patient that something has given way
Drainage that is odorous and purulent
Protrusion of visceral organs through a wound opening
Chronic drainage of fluid through the incision site
The Correct Answer is A
A. Report by patient that something has given way: A patient reporting a "giving way" sensation is a classic early sign of dehiscence, indicating that the wound edges are separating.
B. Drainage that is odorous and purulent: Purulent (pus-like) and foul-smelling drainage suggests infection, not necessarily dehiscence. Infection can contribute to dehiscence, but it is not the defining feature.
C. Protrusion of visceral organs through a wound opening: Evisceration occurs when internal organs protrude through the incision. Dehiscence is partial or complete separation of the wound edges without organ protrusion.
D. Chronic drainage of fluid through the incision site: Persistent drainage suggests a fistula (abnormal connection between tissues), infection, or poor wound healing, rather than wound dehiscence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Assess the pedal pulses for a full minute. Pedal pulses assess circulation to the lower extremities and are not related to confirming an irregular heart rate.
B. Assess the apical pulse with a Doppler device. A Doppler is not typically necessary to assess the apical pulse unless pulses are difficult to detect due to poor circulation.
C. Assess the apical pulse for a full minute. When an irregular radial pulse is detected, the most accurate way to assess heart rate and rhythm is by auscultating the apical pulse for a full minute. This helps determine the presence of arrhythmias.
D. Assess the pedal pulses with a Doppler device. Checking pedal pulses with a Doppler is useful for assessing circulation in the lower extremities but does not help confirm an irregular heart rate.
Correct Answer is C
Explanation
A. Hold the hands higher than the elbows. Hands should be held lower than the elbows to allow water to flow from the fingertips downward, preventing contamination of clean areas by dirty water.
B. Rub hands and arms to dry. Hands should be dried by patting rather than rubbing to prevent skin irritation. Also, drying should focus on the hands first, then the wrists, and then the forearms to avoid recontamination.
C. Apply 4 to 5 mL of liquid soap to the hands. The recommended amount of liquid soap is 3 to 5 mL to effectively remove microorganisms. Using too little may not clean adequately, and using too much can make rinsing difficult.
D. Adjust the water temperature to feel hot. Water should be warm, not hot, to prevent skin irritation and dryness. Hot water can damage the skin’s natural protective barrier, increasing susceptibility to infection.
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