The nurse is caring for a patient who has experienced a total abdominal hysterectomy. Which nursing observation of the incision will indicate the patient is experiencing a complication of wound healing?
a. The site is hurting.
b. The site is approximated.
c. The site has started to itch.
d. The site has a mass, bluish in color.
ANS: D
A hematoma is a localized collection of blood underneath the tissues. It appears as swelling, change in color, sensation, or warmth or a mass that often takes on a bluish discoloration. A hematoma near a major artery or vein is dangerous because it can put pressure on the vein or artery and obstruct blood flow. Itching is not a complication. Incisions should be approximated with edges together; this is a sign of normal healing. After surgery, when nerves in the skin and tissues have been traumatized by the surgical procedure, it is expected that the patient will experience pain.
You might also like to view...
A 57-year-old CEO of a large corporation presented at his primary physician's office with complaints of rectal bleeding and occasional lower abdominal pain. The nurse assessing the patient should suspect what?
A) Ulcer B) Crohn's disease C) Rectal polyps D) Inflammatory bowel disease
A nursing instructor supervises a student nurse who is administering an intramuscular analgesic medication to a school-age child. The nursing instructor intervenes when the student nurse tells the child:
1. "My injections don't hurt." 2. "This will only hurt for a little while." 3. "This will feel like a prick and will hurt a little." 4. "This medication will help take your pain away."
A nurse performs an assessment of a client in a long-term care facility and records baseline data. The nurse reassesses the client a month later and makes revisions in the plan of care. What type of assessment is the second assessment?
A) Comprehensive B) Focused C) Time-lapsed D) Emergency
A client's condition has deteriorated and the nurse needs to notify the health care provider. What information should the nurse include when providing a telephone report on this client?
1. Client's medical diagnosis 2. Name of unit nurse manager 3. Names of family members visiting 4. Name and relationship to the client 5. Observed changes in the client's status