Nokea
All of the following are found during your assessment of a surgical wound. Which would concern you the most?
- A. Edges of the wound are together except for a 1-cm area at the distal end, which is open approximately 1.5 cm.
- B. All sutures are intact, but one suture is somewhat looser than the other sutures.
- C. The 2-cm margin around the wound is red, warm, and swollen.
- D. The patient complains of increasing pain in the incisional area compared to yesterday.
Correct Answer: C
Rationale: Redness, warmth, and swelling around the wound margin are signs of infection, which is most concerning and requires prompt intervention.
You may also like to solve these questions
The drainage on the dressing over a patient's old IV site is clear and slightly yellow. This drainage is described as
- A. Serosanguineous
- B. Sanguineous
- C. Serous
- D. Purulent
Correct Answer: C
Rationale: Serous drainage is clear or slightly yellow fluid, often seen in healing wounds or minor injuries like an old IV site.
Which of the following orders would you expect the health-care provider to write after receiving laboratory results for the patient in Question 20?
- A. Bedrest with bathroom privileges
- B. Discharge tomorrow morning
- C. Wound culture and sensitivity
- D. Low-protein diet
Correct Answer: C
Rationale: A wound culture and sensitivity test is appropriate to identify the specific bacteria and effective antibiotics for an infected wound.
The drainage in a patient's Jackson-Pratt drain is red and appears bloody. This drainage is described as
- A. Serosanguineous
- B. Sanguineous
- C. Serous
- D. Purulent
Correct Answer: B
Rationale: Sanguineous drainage is characterized by red, bloody fluid, typically seen in fresh wounds or surgical drains like a Jackson-Pratt drain.
An elderly patient who lives alone and has a vascular stasis ulcer on his right leg is most at risk for infection because he
- A. May not see well enough to notice changes in the wound that indicate infection.
- B. Is unable to stay off of his leg, which will compromise circulation to the area.
- C. Does not eat healthy meals, causing a lack of granulation tissue.
- D. Lacks the ability to understand the way that antibiotics work.
Correct Answer: A
Rationale: Poor vision in the elderly can prevent early detection of infection signs, increasing infection risk in chronic wounds like stasis ulcers.
A colonized wound is one in which
- A. There is potential for becoming infected.
- B. Infection is present as a result of gross contamination related to trauma.
- C. Infection is present as evidenced by high numbers of microorganisms and either purulent drainage or necrotic tissue.
- D. A high number of microorganisms are present without signs and symptoms of infection.
Correct Answer: D
Rationale: A colonized wound has many microorganisms but no clinical signs of infection, distinguishing it from an infected wound.