It is also the nurse's function to determine when infection is developing in the surgical incision. The perioperative nurse should observe for what signs of impending infection?

Correct Answer: A

Rationale: The correct answer is A: Localized heat and redness. This is because heat and redness are classic signs of inflammation, which can indicate an infection developing in a surgical incision. The increased blood flow to the area causes heat, and the dilation of blood vessels causes redness. Serosanguinous exudates (choice B) and separation of the incision (choice C) are more indicative of normal wound healing or other complications rather than infection. Blood clots and scar tissue (choice D) are not typical signs of impending infection.

Correct Answer: C

Rationale: Rationale: Choice C is correct because eating balanced meals at regular intervals helps regulate colostomy function by maintaining consistent digestion and bowel movements. This ensures proper nutrient absorption and prevents complications. Summary of other choices: A: Irrigating after lunch is unnecessary and can disrupt the natural bowel function. B: While fruits and vegetables are important for overall health, they do not specifically regulate colostomy function. D: Restricting exercise to walking only may not be sufficient for promoting regular bowel movements and overall health.

Correct Answer: D

Rationale: The correct answer is D: Semiformed. This indicates proper colostomy function. Green liquid (A) suggests rapid transit time. Solid formed (B) can indicate constipation. Loose, bloody (C) indicates inflammation or infection. Semiformed (D) is the ideal consistency for colostomy drainage, indicating proper digestion and absorption.

Correct Answer: A

Rationale: The correct answer is A because a decreased blood pressure from 160/90 to 110/70 may indicate increasing intracranial pressure. This is due to the body's compensatory mechanism to decrease blood flow to the brain, resulting in a lower blood pressure. Choices B, C, and D do not directly correlate with increasing intracranial pressure. Choice B may indicate some cardiac dysfunction, C indicates sleepiness which could be due to fatigue or pain, and D is related to loss of appetite which is not specific to intracranial pressure.

Correct Answer: A

Rationale: The correct answer is A: Bone fracture. Osteoporosis is a condition characterized by weakened bones, making the individual more susceptible to fractures. Teaching the client about this major complication is crucial for prevention and management. Fractures are a significant concern due to the increased risk of falls and fragility of the bones. Loss of estrogen (choice B) is a contributing factor to osteoporosis but not a major complication. Negative calcium balance (choice C) is a consequence of osteoporosis but not the primary major complication. Dowager's hump (choice D) is a visible sign of advanced osteoporosis but not the major complication. Overall, educating the client about bone fractures is essential for their understanding and proactive measures to prevent further complications.