While cleansing a client's surgical incision, the nurse observes the incision as seen in the picture. How should the nurse document the appearance of the incision?

Dehiscence present.

Incision healing well.

Infected incision.

Edges approximated.

Answer and Explanation

The Correct Answer is D

A.   Dehiscence refers to the separation or opening of a wound’s edges, usually occurring after surgical closure. This can be due to several factors including infection, mechanical stress, or inadequate wound healing. If the incision shows signs of separation or gaping, this term would be appropriate. However, without a visual description or image, it’s unclear if the incision exhibits these characteristics.
B.   This term implies that the incision is progressing towards recovery with no significant issues such as infection or dehiscence. This documentation is used when the wound appears clean, dry, and without signs of complications.
C.   An infected incision typically shows signs such as increased redness, warmth, swelling, purulent drainage, or an unpleasant odor. If the incision displays these signs, it would be appropriate to document it as infected.
D.   This term indicates that the edges of the incision are closely aligned, which is often used to describe an incision that is healing by primary intention. The edges are expected to come together neatly without separation.

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Correct Answer is B

Explanation

A. CRP is an acute-phase protein produced by the liver in response to inflammation. Elevated CRP levels indicate systemic inflammation or infection. Measuring the CRP level can help confirm the presence of an inflammatory process, such as infection, and monitor the severity of inflammation. However, while useful, CRP alone might not provide the complete picture needed for specific wound management.
B. Culturing the wound for sensitive organisms is crucial when an infection is suspected. This test will identify the specific bacteria or other pathogens causing the infection and determine their sensitivity to various antibiotics. This information is essential for choosing the appropriate treatment to address the infection effectively.
C. Serum albumin levels provide information about the client’s nutritional status and can reflect protein malnutrition. Low serum albumin levels can indicate poor wound healing due to inadequate protein levels, which affects tissue repair. While serum albumin is important for understanding overall nutritional status, it does not directly diagnose or confirm infection.
D. Blood glucose levels are important to monitor, especially in diabetic patients, as high blood glucose can impair wound healing and increase the risk of infections. However, blood glucose levels are more related to the client's ability to heal rather than directly identifying or managing an infection.

A. Document the presence of orthopnea. B. Elevate the head of the bed. C. Obtain a pulse oximeter. D. Assess the client's vital signs.

Correct Answer is B

Explanation

A. Orthopnea is a condition where a person has difficulty breathing when lying flat and may require sitting or standing to breathe more easily. While documenting orthopnea is important for the medical record and understanding the client’s condition, it is not the immediate priority in addressing acute breathing difficulty.
B. Elevating the head of the bed is an immediate and effective action to help alleviate breathing difficulty. This position helps improve respiratory mechanics by allowing the diaphragm to move more freely and reducing pressure on the lungs.
C. Using a pulse oximeter to measure oxygen saturation is important for assessing the client’s oxygen levels and determining the need for supplemental oxygen. However, this action is secondary to immediately addressing the position that is causing difficulty.
D. Assessing vital signs is important for a comprehensive evaluation of the client’s overall condition and to identify any critical changes in health status. However, in the case of immediate breathing difficulty, it is more urgent to take actions that directly address the breathing issue before performing a thorough assessment.

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While cleansing a client's surgical incision, the nurse observes the incision as seen in the picture. How should the nurse document the appearance of the incision?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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