A nurse is caring for a client with a wound. Which of the following pairings reflect the correct wound infection stage with description?

Colonization - replicating microorganisms: not yet Infected

Systemic infection - Wound is darker than the surrounding skin with noted drainage present

Contaminated - infection beyond the wound

Local infection - sepsis

Answer and Explanation

The Correct Answer is A

A. Colonization - replicating microorganisms: not yet Infected

This pairing is correct. Colonization refers to the presence and replication of microorganisms on the wound surface. At this stage, the wound is not yet infected, as there may be microorganisms present, but they have not caused an inflammatory response or tissue damage.

B. Systemic infection - Wound is darker than the surrounding skin with noted drainage present

This description does not match the stage of systemic infection. Systemic infection refers to an infection that has spread beyond the initial wound site, affecting the entire body systemically. The symptoms of systemic infection may include fever, increased heart rate, malaise, and altered mental status. The description provided seems more indicative of a local infection with drainage.

C. Contaminated - infection beyond the wound

This pairing is incorrect. Contaminated wounds refer to wounds with a high risk of infection due to the presence of foreign material or significant contamination. However, contamination does not necessarily mean that an infection has already developed beyond the wound. It signifies a risk of infection but does not define the infection stage itself.

D. Local infection - sepsis

This pairing is incorrect. A local infection is confined to the wound site and may present with symptoms such as erythema, warmth, swelling, pain, and purulent drainage. Sepsis, on the other hand, is a severe systemic response to infection, characterized by widespread inflammation and organ dysfunction. Sepsis is not synonymous with a local infection; it represents a more advanced and life-threatening stage of infection.

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Correct Answer is A

Explanation

A. Full thickness:

Full-thickness burns involve damage to the entire thickness of the skin, including the epidermis and dermis. They often result in a white, charred, or leather-like appearance and are typically painless due to nerve damage. In the context of the patient's data, the description of "bilateral leg burns present with a white and leather-like appearance" indicates that the burns have penetrated deeply into the skin, suggesting full-thickness burns. The absence of blisters or bleeding is also consistent with full-thickness burns, as these burns often destroy the structures that would form blisters.

B. Superficial:

Superficial burns, also known as first-degree burns, only affect the outer layer of the skin (epidermis).They are characterized by redness, pain, and swelling but do not typically result in blisters or significant skin damage. The patient's description of "white and leather-like appearance" and the absence of blisters or bleeding are not indicative of superficial burns. Therefore, superficial burns are not an appropriate categorization based on the provided data.

C. Partial-thickness superficial:

Partial-thickness superficial burns, also known as second-degree superficial burns, affect the epidermis and part of the dermis. They are characterized by redness, blister formation, and pain. However, the description of "white and leather-like appearance" does not align with partial-thickness superficial burns, as these burns typically do not result in a white or charred appearance. Additionally, the absence of blisters or bleeding is not consistent with partial-thickness superficial burns.

D. Partial-thickness deep:

Partial-thickness deep burns, also known as second-degree deep burns, extend deeper into the dermis compared to partial-thickness superficial burns but do not penetrate through the entire dermis. They are characterized by redness, blister formation, and moderate to severe pain. The absence of blisters or bleeding and the description of "white and leather-like appearance" are more indicative of full-thickness burns rather than partial-thickness deep burns.

A. “All preoperative patients get this medication." B. “The physician prescribed this medication for you." C. "It helps present ulcers from the stress of the surgery." D. “Since you don't have ulcers, I will have to ask."

Correct Answer is C

Explanation

A. “All preoperative patients get this medication.” This statement is too broad and not entirely accurate. While many preoperative patients do receive famotidine (Pepcid), it’s not a standard for all. Medications are prescribed based on individual patient needs and medical history.

B. “The physician prescribed this medication for you.” While this is technically true, it doesn’t provide the patient with an understanding of why the medication is necessary. As a nurse, part of your role is to educate patients about their medications.

C. “It helps prevent ulcers from the stress of the surgery.” This is the correct answer. Famotidine (Pepcid) is given to decrease the amount of acid produced in the stomach, which can help prevent stress ulcers that can occur due to the physical stress of surgery.

D. “Since you don’t have ulcers, I will have to ask.” This statement suggests uncertainty and a lack of knowledge about the medication’s purpose. It’s important for healthcare professionals to understand the medications they administer and be able to explain them to patients.

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A nurse is caring for a client with a wound. Which of the following pairings reflect the correct wound infection stage with description?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse reviews the following data in the chart of a patient with burn injuries: Based on the data provided, how would the nurse categorize this patients injuries?

Correct Answer is A

Explanation

A nurse is giving a preoperative patient a dose of famotidine ( Pepcid). The patient asks why the nurse is giving this drug when the patient has no history of ulcers. What response by the nurse is best?

Correct Answer is C

Explanation

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