A nurse is assessing a client who has a stage 3 pressure injury. Which of the following findings indicates possible infection of the wound?
Serosanguineous drainage
Granulation tissue
Localized tenderness
Moist wound bed
The Correct Answer is C
A. Serosanguineous drainage: Serosanguineous drainage, which is a mixture of serum and blood, is common and expected in the early stages of wound healing, including stage 3 pressure injuries. It does not necessarily indicate infection.
B. Granulation tissue: Granulation tissue is a sign of healthy wound healing. It appears as red, moist tissue and indicates that the wound is healing properly, so it does not suggest infection.
C. Localized tenderness: Localized tenderness around the wound can be a sign of infection. Infection can cause pain, redness, warmth, and tenderness at the site of the pressure injury. It is important to monitor for other signs of infection, such as increased drainage or changes in wound color.
D. Moist wound bed: A moist wound bed is generally beneficial for wound healing and does not indicate infection. In fact, keeping the wound moist helps promote granulation tissue formation and wound closure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Place a towel over the area to be percussed: A towel should be placed over the area to be percussed to protect the skin and to reduce discomfort. This is a standard procedure to ensure that the percussion is effective and comfortable for the client.
B. Ask the client to take shallow, rapid breaths: Shallow, rapid breaths should be avoided during chest percussion. The client should take deep, slow breaths to help mobilize secretions and allow for effective lung expansion. Rapid breathing could increase respiratory distress.
C. Percuss over each area for 10 min: Percussion should not be performed for 10 minutes over each area, it is done for 1-2 minutes over each lung field to help loosen mucus and improve drainage. Prolonged percussion could be harmful and unnecessary.
D. Maintain client positioning for 45 min: Typically, positioning is maintained for short periods (usually 10-15 minutes) depending on the area being targeted for percussion. Prolonged positioning may lead to discomfort or other complications.
Correct Answer is A
Explanation
A. Soiled cat litter: Clients with HIV are at increased risk for infections, including toxoplasmosis, which can be contracted from handling soiled cat litter. The nurse should instruct the client to avoid contact with cat litter to prevent exposure to these pathogens.
B. Pasteurized milk: Pasteurized milk is safe to consume and does not pose a significant risk for infection in clients with HIV. The pasteurization process kills harmful bacteria, making it safe for immunocompromised individuals.
C. Scrambled eggs: Scrambled eggs are safe to eat as long as they are properly cooked. The risk of infection from eggs is primarily related to undercooking, which is not specific to HIV-positive clients.
D. Electric razor: An electric razor is safe to use, provided it is kept clean and sanitized. Disposable razors or proper hygiene practices can prevent the risk of cuts and infections, which is not specific to HIV-positive individuals.
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