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. Stop the infusion of IV fluids:

This action may be appropriate if there are signs of infiltration or extravasation, where the IV fluid leaks into the surrounding tissue instead of entering the vein. Stopping the infusion can help prevent further tissue damage and assess the extent of the infiltration.

B. Apply cold compresses to the IV site:

Cold compresses can help reduce swelling and discomfort at the IV site. This action may be appropriate if there are signs of local inflammation or mild irritation at the insertion site.

C. Elevate the extremity on a pillow:

Elevating the extremity can help reduce swelling and promote venous return. This action is beneficial if there is edema or localized swelling above the IV site.

D. Flush the catheter with normal saline:

Flushing the catheter with normal saline is not typically the initial action in response to edema and tenderness above the IV site. Flushing is more commonly performed to ensure patency and proper functioning of the IV catheter.

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 assesses a patient’s peripheral IV site and notices edema and tenderness above the site. What action will the nurse take next?

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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