A nurse is assessing a patient with a surgical wound healing by secondary intention. Which finding should the nurse report to the charge nurse?
The wound is tender to touch.
The wound has a halo of erythema on the surrounding skin.
The wound is draining serosanguineous fluid.
The wound has pink, shiny tissue with a granular appearance.
The Correct Answer is B
Choice A rationale:
Tenderness to touch is a common finding in wounds healing by secondary intention. It's often due to inflammation, which is a normal part of the healing process. The inflammation brings in cells and substances that promote healing. However, increased tenderness, especially when accompanied by other signs of infection, should be reported.
Choice B rationale:
A halo of erythema on the surrounding skin is a sign of infection. This is a serious complication that can delay healing and lead to further complications. The erythema indicates that the infection is spreading beyond the wound edges and needs prompt attention.
Choice C rationale:
Drainage of serosanguineous fluid is also common in wounds healing by secondary intention. This fluid is a mixture of serum (clear yellowish fluid) and blood. It's a sign that the wound is cleaning itself and new tissue is forming. While excessive drainage or a change in color or odor could signal a problem, drainage itself is not necessarily a cause for concern.
Choice D rationale:
Pink, shiny tissue with a granular appearance is a sign of healthy granulation tissue. This is a type of tissue that forms during the healing process. It's rich in blood vessels and collagen, which are essential for wound healing. The presence of granulation tissue indicates that the wound is healing well.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
While explaining the importance and rationale of the new policy may be helpful in some cases, it may not be sufficient for nurses who are resistant to change. This approach assumes that the nurse's resistance is due to a lack of understanding, which may not be the case. It's possible that the nurse understands the rationale but has other concerns or objections.
Focusing solely on explaining the rationale can make the nurse feel they are not being listened to or that their concerns are not being valued. This can further contribute to resistance.
Choice B rationale:
Encouraging the nurse to verbalize their reasons for resistance allows the nurse manager to understand the root cause of the resistance. This could include:
Concerns about the effectiveness of the new policy
Belief that the new policy will create more work or make their job more difficult
Feeling that they were not adequately consulted or involved in the decision-making process Personal factors such as fear of change or a preference for established routines
Once the nurse manager understands the nurse's concerns, they can work together to address them and find ways to facilitate acceptance of the new policy. This approach fosters open communication, collaboration, and shared decision-making, which are essential for successful change management.
Choice C rationale:
Indicating disciplinary consequences may be necessary in some cases, but it should be a last resort. It can create a negative and hostile work environment, further alienate the nurse, and potentially lead to resentment and decreased morale among other staff members.
It's important to prioritize understanding and addressing the underlying reasons for resistance before resorting to disciplinary measures.
Choice D rationale:
Ignoring the resistance and relying on peer pressure is a passive and ineffective approach. It does not address the nurse's concerns and may even exacerbate the situation. This can lead to conflict among staff members, create a divide between those who support the change and those who resist it, and potentially compromise patient care.
Correct Answer is C
Explanation
Choice A rationale:
Recapping needles is a dangerous practice that significantly increases the risk of needlestick injuries.
The act of recapping involves directing the sharp end of the needle towards one's hand, creating a high likelihood of accidental puncture.
Even experienced healthcare professionals are susceptible to needlestick injuries during recapping.
Wastebaskets are not designed for the safe disposal of sharps and can easily be punctured, leading to potential exposure to bloodborne pathogens.
Choice B rationale:
While it is true that needles should not be recapped on ABG specimens, this option does not address the broader issue of safe needle disposal in general.
Focusing solely on ABG specimens could lead to the misconception that recapping is acceptable for other types of needles.
Choice D rationale:
Breaking needles in half is not recommended as a standard practice for needle disposal.
This action can create sharp fragments that are difficult to handle and can still cause injuries.
Sharps disposal containers are designed to safely contain intact needles and should be used as the primary method of disposal.
Choice C rationale:
Placing uncapped needles directly into a puncture-proof container is the safest and most recommended practice for needle disposal.
These containers are specifically designed to prevent needlestick injuries by shielding the sharps from accidental contact. They are typically made of hard plastic or metal and are clearly labeled for biohazard waste.
Using puncture-proof containers consistently for all needle disposal significantly reduces the risk of needlestick injuries among healthcare workers.
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