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 ["A","B","D","E"]

Explanation

A. The cheeks can be affected by the nasal cannula, especially if it is not positioned properly or if it causes irritation over time.
B. The area around the nostrils is one of the most common sites for skin damage related to nasal cannulas. Continuous contact with the cannula can cause irritation, redness, or even sores in this area.
C. The nasal cannula itself does not typically make contact with the forehead. Therefore, skin damage across the forehead is not generally a concern related to the use of a nasal cannula.
D. The bridge of the nose is a key area to inspect for skin damage. The nasal cannula’s prongs often rest on or near the bridge of the nose, which can lead to pressure sores, redness, or irritation in this area. Regular assessment is important to prevent and address any damage.
E. The tops of the ears can be affected if the nasal cannula’s tubing or securing mechanism (such as behind-the-ear supports or loops) causes friction or pressure. Skin breakdown can occur in this area if the cannula is not properly adjusted or if it causes irritation.

A. Picks up an item on the far side of the bed by stretching over the mattress. B. Bends at the waist to hang a urinary bedside unit on the bed frame. C. Pushes the lower drawer of the medication cart closed using one's hip. D. Stands erect with knees bent to pull a draw sheet and move the client in bed.

Correct Answer is D

Explanation

A. This can strain the back and increase the risk of injury. It's important to use proper body mechanics, such as bending the knees and keeping the back straight, when reaching for objects.
B. Bending at the waist can strain the back and increase the risk of injury. It's important to lift objects with the legs, not the back.
C. This can strain the back and hips. It's important to use proper body mechanics, such as using the legs and core muscles to push or pull heavy objects.
D. Standing erect with knees bent provides a strong base of support and helps to distribute weight evenly. Bending the knees allows for lifting with the legs, which is less stressful on the back and reduces the risk of injury. Pulling a draw sheet and moving a client in bed requires a combination of strength and proper body mechanics. Standing erect with knees bent helps to prevent strain on the back and muscles

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses a client who has a nasal cannula delivering oxygen at 2 liters/minute. To assess for skin damage related to the cannula, what areas should the nurse observe? Select all that apply.

Correct Answer is ["A","B","D","E"]

Explanation

The charge nurse is observing a new nurse administering care during new hire orientation at the hospital. Which activity by the new nurse indicates correct body movement and posture to reduce the risk for injury?

Correct Answer is D

Explanation

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