A nurse is caring for a client in a wound center.
Click to highlight the findings that indicate therapy has been ineffective. To deselect a finding, click on the finding again.
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. Urine output 25 mL/hr: Urine output less than 30 mL/hr is considered inadequate, especially after surgery. This could indicate possible renal insufficiency or hypovolemia, requiring immediate attention.
B. Heart rate 68/min: A heart rate of 68/min falls within the normal adult range (60-100 beats per minute). This finding is generally considered stable and does not typically indicate an immediate complication requiring urgent reporting to the provider in a postoperative client.
C. Hypoactive bowel sounds: Hypoactive bowel sounds are common in the immediate postoperative period, especially after abdominal surgery. This occurs due to the effects of anesthesia and bowel manipulation.
D. Serosanguineous drainage on surgical dressing: Serosanguineous drainage is typical in the early postoperative period and usually decreases over time. It’s not abnormal unless the amount increases significantly or the drainage becomes purulent.
Correct Answer is A
Explanation
A. Fold the existing patch on itself and dispose of it in a childproof container: The nurse should remove the old patch before applying a new one to avoid excessive medication delivery. The patch should be folded on itself to prevent accidental exposure to the medication and disposed of safely in a childproof container to prevent potential harm.
B. Shave the client's lower leg for placement of the new patch: Shaving can irritate the skin and increase the absorption of the medication, leading to an increased risk of side effects. The patch should be applied to clean, dry, and intact skin without shaving the area.
C. Keep the existing patch on and place the new patch in a different location: The old patch should be removed before applying a new one to prevent an overdose of medication. Placing a new patch over an old one can lead to excessive drug absorption,.
D. Discard the old patch and apply a new one in the same location: While the old patch should be discarded, it is not recommended to apply a new patch in the exact same location. Rotating the patch sites is important to prevent skin irritation and promote better absorption.
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