Question

Five days after a client has abdominal surgery, a nurse assesses the client's incision site for signs of dehiscence. Which clinical finding supports the nurse's conclusion that the client is experiencing wound dehiscence?

A) Absence of serosanguineous drainage
B) Incision site feels warm and tender
C) Closure of the incision site
D) Protrusion of abdominal contents through the incision

Answer 1

The clinical finding indicating wound dehiscence is the protrusion of abdominal contents through the incision. It is a serious complication necessitating immediate medical intervention.

Step-by-step explanation:

When assessing an abdominal surgery incision site for signs of wound dehiscence, the clinical finding that supports the diagnosis of dehiscence is D) Protrusion of abdominal contents through the incision.

Wound dehiscence is a serious postoperative complication where the edges of a surgical incision fail to stay together, which can result in the protrusion of internal organs through the open incision. This condition is considered a surgical emergency and requires immediate medical attention to prevent further complications, such as infection or evisceration.

Warmth and tenderness at the incision site, absence of serosanguineous drainage, and closure of the incision site may indicate other issues such as infection but are not typically signs of wound dehiscence.