A nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical
... [Show More] site?
1. Red, hard skin
2. Serous drainage
3. Purulent drainage
4. Warm, tender skin
2. Serous drainage
Rationale: Serous drainage is an expected finding at a surgical site. The other options indicate signs of wound infection. Signs and symptoms of infection include warm, red, and tender skin around the incision. Wound infection usually appears 3 to 6 days after surgery. The client also may have a fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique or a contaminated wound before surgical exploration; existing client conditions such as diabetes mellitus or immunocompromise may place the client at risk.
Test-taking strategy: Use the process of elimination, noting the strategy words normal finding. Recalling the signs of a wound infection and noting these strategy words will direct you to option 2. Review the signs of a wound infection if you had difficulty with this question.
When performing a surgical dressing change of a client's abdominal dressing, a nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. The nurse should do which of the following in the initial care of this wound?
1. Leave the incision open to the air to dry the area.
2. Irrigate the wound and apply a sterile dry dressing.
3. Apply a sterile dressing soaked with normal saline.
4. Apply a sterile dressing soaked in providone-iodine (Betadine).
3. Apply a sterile dressing soaked with normal saline.
Rationale: Wound dehiscence is the separation of wound edges at the suture line. Signs and symptoms include increased drainage and the appearance of underlying tissues. Dehiscence usually occurs 6 to 8 days after surgery. The client should be instructed to remain quiet and avoid coughing or straining. The client should be positioned to prevent further stress on the wound (semi-Fowler's). Sterile dressings soaked with sterile normal saline should be used to cover the wound. The nurse must notify the physician after applying the initial dressing to the wound. Options 1, 2, and 4 are incorrect.
Test-taking strategy: Use the process of elimination. Eliminate option 1 first because this action would dry the wound and also present a risk of infection to the underlying tissues. Eliminate options 2 and 4 next because a dry dressing and a dressing soaked with providone-iodine will irritate the exposed body tissues. Review initial nursing care when dehiscence or evisceration occurs if you had difficulty with this question.
A nurse is monitoring the status of a postoperative client. The nurse would become most concerned with which of the following signs that could indicate an evolving complication?
1. Increasing restlessness
2. A negative Homans' sign
3. Hypoactive bowel sounds in all four quadrants
4. Blood pressure of 110/70 mm Hg and a pulse of 86 beats/min
1. Increasing restlessness
Rationale: Increasing restlessness is a sign that requires continuous and close monitoring because it could indicate a potential complication, such as hemorrhage, shock, or pulmonary embolism. A blood pressure of 110/70 mm Hg with a pulse of 86 beats/minute is within normal limits. Hypoactive bowel sounds heard in all four quadrants are a normal occurrence, as is a negative Homans' sign (A positive Homans' sign may indicate thrombophlebitis).
Test-Taking Strategy: Use the process of elimination and note the strategic word, "most". Focus on the subject , "a manifestation of an evolving complication". Eliminate each of the incorrect options because they are comparable or alike and are normal expected findings. If you had difficulty with this question, review the normal expected postoperative findings and the signs and symptoms of postoperative complications.
A nurse is reviewing a physician's order sheet for a preoperative client that states that the client must be NPO after midnight. The nurse would telephone the physician to clarify whether which of the following medications should be given to the client and not withheld?
1. Ferrous sulfate
2. Prednisone (Deltasone)
3. Cycloenzaprine (Flexeril)
4. Conjugated estrogen (Premarin)
2. Prednisone (Deltasone)
Rationale: Prednisone is a corticosteroid. With prolonged use, corticosteroids cause adrenal atrophy, which reduces the ability of the body to withstand stress. When stress is severe, corticosteroids are essential to life. Before and during surgery, dosages may be increased temporarily. Ferrous sulfate is an oral iron preparation used to treat iron deficiency anemia. Cyclobenzaprine (Flexeril) is a skeletal muscle relaxant. Conjugated estrogen (Premarin) is an estrogen used for hormone replacement therapy in postmenopausal women. These last three medications may be withheld before surgery without undue effects on the client.
Test-Taking Strategy: Use the process of elimination and knowledge about medications that may have special implications for the surgical client. Focus on the subject, the medication that should be administered in the preoperative period. Remember that when stress is severe, corticosteroids are essential to life. Review the effects of corticosteroids if you had difficulty with this question.
A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which of the following laboratory results should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed?
1. Sodium, 141 mEq/L
2. Hemoglobin, 8.0 g/dL
3. Platelets, 210,000/mm3
4. Serum creatinine, 0.8 mg/dL
2. Hemoglobin, 8.0 g/dL
Rationale: Routine screening tests include a complete blood count, serum electrolyte analysis, coagulation studies, and a serum creatinine test. The complete blood count includes the hemoglobin analysis. All these values are within normal range except for hemoglobin. If a client has a low hemoglobin level, the surgery likely could be postponed by the surgeon.
Test-Taking Strategy: Focus on the subject , an abnormal laboratory result that needs to be reported. Use knowledge of the normal laboratory values to assist in answering correctly. The hemoglobin value is the only incorrect laboratory finding. Review these laboratory values if you had difficulty answering this question. [Show Less]