Saunders Comprehensive Review for
the NCLEX-RN Exam Pre-op, Intra-op,
Post-op Questions & Answers (Grade
A+)
A nurse assesses a client's surgical incision for signs of infection.
Which finding by the nurse would be interpreted as a normal
finding at the surgical site?
1. Red, hard skin
2. Serous drainage
3. Purulent drainage
4. Warm, tender skin -
correct answer ✅2. Serous drainage
Rationale: Serous drainage is an expected finding at a surgical site.
The other options indicate signs of wound infection. Signs and
symptoms of infection include warm, red, and tender skin around
the incision. Wound infection usually appears 3 to 6 days after
surgery. The client also may have a fever and chills. Purulent
material may exit from drains or from separated wound edges.
Infection may be caused by poor aseptic technique or a
contaminated wound before surgical exploration; existing client
conditions such as diabetes mellitus or immunocompromise may
place the client at risk.
,Saunders Comprehensive Review for
the NCLEX-RN Exam Pre-op, Intra-op,
Post-op Questions & Answers (Grade
A+)
Test-taking strategy: Use the process of elimination, noting the
strategy words normal finding. Recalling the signs of a wound
infection and noting these strategy words will direct you to option
2. Review the signs of a wound infection if you had difficulty with
this question.
When performing a surgical dressing change of a client's abdominal
dressing, a nurse notes an increase in the amount of drainage and
separation of the incision line. The underlying tissue is visible to the
nurse. The nurse should do which of the following in the initial care
of this wound?
1. Leave the incision open to the air to dry the area.
2. Irrigate the wound and apply a sterile dry dressing.
3. Apply a sterile dressing soaked with normal saline.
4. Apply a sterile dressing soaked in providone-iodine (Betadine). -
correct answer ✅3. Apply a sterile dressing soaked with normal
saline.
Rationale: Wound dehiscence is the separation of wound edges at
the suture line. Signs and symptoms include increased drainage and
the appearance of underlying tissues. Dehiscence usually occurs 6
, Saunders Comprehensive Review for
the NCLEX-RN Exam Pre-op, Intra-op,
Post-op Questions & Answers (Grade
A+)
to 8 days after surgery. The client should be instructed to remain
quiet and avoid coughing or straining. The client should be
positioned to prevent further stress on the wound (semi-Fowler's).
Sterile dressings soaked with sterile normal saline should be used
to cover the wound. The nurse must notify the physician after
applying the initial dressing to the wound. Options 1, 2, and 4 are
incorrect.
Test-taking strategy: Use the process of elimination. Eliminate
option 1 first because this action would dry the wound and also
present a risk of infection to the underlying tissues. Eliminate
options 2 and 4 next because a dry dressing and a dressing soaked
with providone-iodine will irritate the exposed body tissues. Review
initial nursing care when dehiscence or evisceration occurs if you
had difficulty with this question.
A nurse is monitoring the status of a postoperative client. The nurse
would become most concerned with which of the following signs
that could indicate an evolving complication?
1. Increasing restlessness
2. A negative Homans' sign
the NCLEX-RN Exam Pre-op, Intra-op,
Post-op Questions & Answers (Grade
A+)
A nurse assesses a client's surgical incision for signs of infection.
Which finding by the nurse would be interpreted as a normal
finding at the surgical site?
1. Red, hard skin
2. Serous drainage
3. Purulent drainage
4. Warm, tender skin -
correct answer ✅2. Serous drainage
Rationale: Serous drainage is an expected finding at a surgical site.
The other options indicate signs of wound infection. Signs and
symptoms of infection include warm, red, and tender skin around
the incision. Wound infection usually appears 3 to 6 days after
surgery. The client also may have a fever and chills. Purulent
material may exit from drains or from separated wound edges.
Infection may be caused by poor aseptic technique or a
contaminated wound before surgical exploration; existing client
conditions such as diabetes mellitus or immunocompromise may
place the client at risk.
,Saunders Comprehensive Review for
the NCLEX-RN Exam Pre-op, Intra-op,
Post-op Questions & Answers (Grade
A+)
Test-taking strategy: Use the process of elimination, noting the
strategy words normal finding. Recalling the signs of a wound
infection and noting these strategy words will direct you to option
2. Review the signs of a wound infection if you had difficulty with
this question.
When performing a surgical dressing change of a client's abdominal
dressing, a nurse notes an increase in the amount of drainage and
separation of the incision line. The underlying tissue is visible to the
nurse. The nurse should do which of the following in the initial care
of this wound?
1. Leave the incision open to the air to dry the area.
2. Irrigate the wound and apply a sterile dry dressing.
3. Apply a sterile dressing soaked with normal saline.
4. Apply a sterile dressing soaked in providone-iodine (Betadine). -
correct answer ✅3. Apply a sterile dressing soaked with normal
saline.
Rationale: Wound dehiscence is the separation of wound edges at
the suture line. Signs and symptoms include increased drainage and
the appearance of underlying tissues. Dehiscence usually occurs 6
, Saunders Comprehensive Review for
the NCLEX-RN Exam Pre-op, Intra-op,
Post-op Questions & Answers (Grade
A+)
to 8 days after surgery. The client should be instructed to remain
quiet and avoid coughing or straining. The client should be
positioned to prevent further stress on the wound (semi-Fowler's).
Sterile dressings soaked with sterile normal saline should be used
to cover the wound. The nurse must notify the physician after
applying the initial dressing to the wound. Options 1, 2, and 4 are
incorrect.
Test-taking strategy: Use the process of elimination. Eliminate
option 1 first because this action would dry the wound and also
present a risk of infection to the underlying tissues. Eliminate
options 2 and 4 next because a dry dressing and a dressing soaked
with providone-iodine will irritate the exposed body tissues. Review
initial nursing care when dehiscence or evisceration occurs if you
had difficulty with this question.
A nurse is monitoring the status of a postoperative client. The nurse
would become most concerned with which of the following signs
that could indicate an evolving complication?
1. Increasing restlessness
2. A negative Homans' sign
