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A patient is at risk for wound dehiscence as a result of nutritional issues and medical history. Which interventions should be included in the care plan?
- A. Assist the patient to splint the incision with a pillow when coughing.
- B. Enforce strict bedrest with bathroom privileges only.
- C. Administer stool softeners and antinausea medicine promptly.
- D. Obtain VS every 15 minutes.
Correct Answer: A,C
Rationale: Splinting the incision and preventing straining (via stool softeners/antinausea meds) reduce stress on the wound, preventing dehiscence.
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During the inflammatory process, which of the following physiological responses occur?
- A. Capillaries dilate, causing erythema and increased warmth at the site of injury.
- B. Leukocytes are shunted away from the site to fight infection.
- C. Leukocytes move into the interstitial space and attack microorganisms.
- D. Red blood cells deliver more oxygen and nutrients to promote healing.
- E. Fluid in the interstitial spaces prevents redness and pain.
- F. Edema causes pressure on nerve endings, resulting in discomfort and pain.
Correct Answer: A,C,D,F
Rationale: During inflammation, capillaries dilate (erythema and warmth), leukocytes migrate to fight infection, red blood cells supply oxygen/nutrients, and edema causes pain. Leukocytes are not shunted away, and fluid does not prevent redness/pain.
The nurse realizes that the patient with a shoulder incision needs more teaching when the patient says
- A. I know the signs of infection and will report them to the physician if they occur.'
- B. If my fever goes above 100 degrees, I will notify my doctor.'
- C. I know how to change the dressing on my incision and have done it three times.'
- D. I will take these antibiotics until the doctor removes the staples.'
Correct Answer: D
Rationale: Antibiotics should be taken for the full prescribed course, not until staples are removed, indicating a need for further teaching.
Match the following types of wound healing with their examples: First intention
- A. A traumatic wound first left open to drain and then sutured closed
- B. An appendectomy incision sutured closed
- C. A pressure ulcer being packed with moist gauze
Correct Answer: B
Rationale: First intention healing occurs when wound edges are closely approximated, as in a sutured appendectomy incision.
A patient has had emergency surgery because of a bowel obstruction. The wound becomes infected with Escherichia coli. This likely occurred because
- A. These bacteria are always present on the skin and easily enter a wound if sterile technique is not used.
- B. These bacteria grow in the absence of oxygen, which is the case in the bowel.
- C. These bacteria are present in the bowel, and with emergency surgery there is no time to perform special bowel preparations.
- D. The patient had poor nutritional intake because these bacteria grow in dying tissue.
Correct Answer: C
Rationale: E. coli, common in the bowel, likely contaminated the wound during emergency surgery due to lack of bowel prep time.
While assessing the skin of a patient on bedrest, you notice a pale area over the left hip with a small blister in the center. What action will you take?
- A. Massage the area vigorously with lotion to promote circulation.
- B. Notify the health-care provider that a pressure injury has developed.
- C. Document your findings and assess again in 2 hours.
- D. Order a special gel-filled mattress for the patient.
Correct Answer: B
Rationale: A pale area with a blister suggests a developing pressure injury, requiring immediate notification of the provider for intervention.