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 A
Explanation
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.
Correct Answer is C
Explanation
A. Calcium channel blocker: Calcium channel blockers (e.g., amlodipine, diltiazem) do not commonly cause a dry cough. They primarily work by relaxing blood vessels and reducing heart workload.
B. Angiotensin II receptor blocker: ARBs (e.g., losartan, valsartan) do not typically cause a persistent cough. They are often prescribed instead of ACE inhibitors for patients who experience this side effect.
C. Angiotensin-converting enzyme (ACE) inhibitors: ACE inhibitors (e.g., lisinopril, enalapril) can cause a persistent dry cough due to the accumulation of bradykinin, a substance that can irritate the airways.
D. Beta-blockers: Beta-blockers (e.g., metoprolol, propranolol) are not commonly associated with a dry cough. They mainly affect heart rate and blood pressure but can cause bronchospasms in some patients.
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