Author Question: A nurse is caring for a patient with a wound. Which assessment data will be most important for the ... (Read 49 times)

lak · **on:** Jul 22, 2018

A nurse is caring for a patient with a wound. Which assessment data will be most important for the nurse to gather with regard to wound healing?

a. Muscular strength assessment
b. Pulse oximetry assessment
c. Sensation assessment
d. Sleep assessment

Question 2

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.

johnharpe · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

ANS: B
Oxygen fuels the cellular functions essential to the healing process; the ability to perfuse tissues with adequate amounts of oxygenated blood is critical in wound healing. Pulse oximetry measures the oxygen saturation of blood. Assessment of muscular strength and sensation, although useful for fitness and mobility testing, does not provide any data with regard to wound healing. Sleep, although important for rest and for integration of learning and restoration of cognitive function, does not provide any data with regard to wound healing.

Answer to Question 2

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.