Difficulty: Medium
Average Score: 62%
Simulated
A nurse is caring for a postoperative patient. Which finding will alert the nurse to a potential wound dehiscence?
Correct answer
B
Rationale
Correct Answer: B - Report by patient that something has given way
Rationale: A patient reporting that something has given way is a key indicator of potential wound dehiscence. This is because the patient may feel a sudden release of tension or pain, indicating that the wound has opened up. This finding is crucial as it can prompt immediate intervention to prevent further complications such as evisceration.
Summary of Incorrect Choices:
A: Chronic drainage of fluid through the incision site - While this can indicate a wound issue, it is not as specific to dehiscence as the patient's report of something giving way.
C: Drainage that is odorous and purulent - This finding suggests infection rather than wound dehiscence.
D: Protrusion of visceral organs through a wound opening - This indicates evisceration, a severe complication that usually follows dehiscence. It is a more advanced sign than the patient's report of something giving way.
Rationale: A patient reporting that something has given way is a key indicator of potential wound dehiscence. This is because the patient may feel a sudden release of tension or pain, indicating that the wound has opened up. This finding is crucial as it can prompt immediate intervention to prevent further complications such as evisceration.
Summary of Incorrect Choices:
A: Chronic drainage of fluid through the incision site - While this can indicate a wound issue, it is not as specific to dehiscence as the patient's report of something giving way.
C: Drainage that is odorous and purulent - This finding suggests infection rather than wound dehiscence.
D: Protrusion of visceral organs through a wound opening - This indicates evisceration, a severe complication that usually follows dehiscence. It is a more advanced sign than the patient's report of something giving way.