Which nursing observation of the incision will indicate the patient is experiencing a complication of wound healing after a total abdominal hysterectomy?

Correct Answer: D

Rationale: A bluish mass suggests a hematoma a complication from blood pooling under tissues, per the text, risking pressure on vessels. Pain and itching are normal post-op. Approximation indicates proper healing. Hematomas require nurse intervention (e.g., notification), making this the correct sign of a healing complication.

Correct Answer: B

Rationale: Dakin's solution is cytotoxic, harming granulation tissue, per the text, and should be questioned for a clean Stage III ulcer. Low-air-loss and hydrogel support healing. Dietitian consults aid nutrition. Noncytotoxic saline is preferred, making this the correct order to challenge.

Correct Answer: C

Rationale: Prevention starts with risk assessment. Determining risk factors (Choice C), per the text, identifies vulnerabilities (e.g., immobility) for tailored interventions. Fluids and nutrition support health but aren't first. Turning is key but follows risk identification. This step ensures effective planning, making it the correct first action.

Correct Answer: A

Rationale: Stage I pressure ulcers intact skin with nonblanchable redness heal without dressings (Choice A), per the text, resolving in 7-14 days with pressure relief. Stage II requires moisture-retentive dressings like hydrocolloids for partial-thickness loss. Stage III and IV need advanced dressings (e.g., hydrogels) for deeper damage. Open-to-air is appropriate only for Stage I, as it avoids unnecessary intervention while promoting natural recovery, making this the correct patient for the nurse's care approach.

Correct Answer: A

Rationale: In a closed wound, like a bruise, the skin remains intact, unlike open wounds with breaks in the skin.