A nurse is caring for a client in a wound center.
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Nurses' Notes
Today:
Client presents for evaluation of wound vac therapy that was applied to surgical wound on their left knee 1 week ago.
Cilent rates pain as 8 on a scale of 0 to 10 in their left knee. Client reports no relief with pain medications.
Respirations even and nonlabored. Heart rate regular and fast. Abdomen soft and nondistended.
Left knee wound vac dressing removed. Left knee wound is 3 cm by 2 cm with 1 cm depth, Wound bed vascular with some approximation of the edges. Mild purulent drainage noted.
Cilent rates pain as 8 on a scale of 0 to 10 in their left knee
Client reports no relief with pain medications
Left knee wound is 3 cm by 2 cm with 1 cm depth
Wound bed vascular with some approximation of the edges
Mild purulent drainage noted
The Correct Answer is ["A","B","C","E"]
Rationale:
- Client rates pain as 8 on a scale of 0 to 10 in their left knee. Client reports no relief with pain medications. The client’s pain has worsened from 4/10 despite pain medication, indicating the current pain management approach is ineffective, and the wound may not be healing as expected.
- Mild purulent drainage noted: The presence of purulent drainage is a sign of infection, further indicating that the wound vac therapy has not been successful in preventing or managing infection at the wound site.
- Left knee wound is 3 cm by 2 cm with 1 cm depth, compared to 2 cm by 2 cm with 1 cm depth one week ago: The increase in wound sizefrom 2cm by 2 cm to 3 cm by 2 cm suggests that the wound vac therapy is not promoting healing effectively, leading to a failure of wound closure.
Rationale for Incorrect Choices:
- Wound bed vascular with some approximation of the edges: The wound bed being vascular with some approximation of the edges indicates that there is some healthy tissue and the edges of the wound are coming together. This suggests that some healing is occurring, although it may be slower than expected.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Holds linens close to the body: Holding linens close to the body reduces the risk of contamination and ensures that the linens do not touch potentially unclean surfaces. This practice helps maintain medical asepsis by preventing the spread of microorganisms.
B. Shakes soiled linens before placing them in the hamper: Shaking soiled linens can cause microorganisms to become airborne and spread. To maintain asepsis, linens should be handled gently and placed directly into the hamper without shaking.
C. Puts unneeded clean linens in the hamper: Clean linens should not be placed in the hamper as they could become contaminated. Clean linens should be stored in a clean area to maintain their aseptic state until needed.
D. Places soiled linens on the floor: Placing soiled linens on the floor introduces the risk of contamination, as the floor is not considered a clean surface. Soiled linens should be placed directly into a designated container to maintain medical asepsis.
Correct Answer is ["D","E","G"]
Explanation
A. Reposition the client every 3 hr: This is insufficient. The standard of care for a client at risk is repositioning at least every 2 hours while in bed and every 1 hour while sitting in a chair to ensure adequate blood flow to compressed tissues.
B. Place the client on a donut-shaped cushion: A donut-shaped cushion is not recommended for preventing pressure ulcers. It can increase pressure on the tissue, leading to further complications. A more effective intervention is use of pressure-redistribution surfaces.
C. Elevate the head of the bed to 45°: Elevating the head of the bed can increase pressure on the sacral area and can be uncomfortable for clients with mobility and incontinence issues. The head of the bed should be elevated only when necessary for breathing or comfort, not as a routine practice.
D. Request a consult with a registered dietitian: The client has decreased intake and may be at risk for malnutrition or dehydration. A dietitian’s input is essential to assess nutritional needs, especially for a client with diabetes and decreased mobility, to ensure proper healing and management.
E. Provide a support pressure-redistribution surface: A support pressure-redistribution surface is crucial for this client to reduce the risk of pressure ulcers. These surfaces help alleviate pressure on bony prominences and distribute the body weight evenly to prevent tissue damage.
F. Perform a skin risk assessment weekly: Skin risk assessments should be done more frequently than weekly, especially for a client with decreased mobility, incontinence, and diabetes. Daily or at least twice-weekly assessments are needed to monitor for early signs of skin breakdown.
G. Use a moisture barrier ointment after cleaning the client's skin: Using a moisture barrier ointment is essential for protecting the skin, especially since the client has urinary and fecal incontinence. This will help prevent skin irritation and breakdown caused by exposure to moisture.
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