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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
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A. Measure the depth and width of the wound. Regular assessment and documentation of the wound’s size can help track the progress of healing and effectiveness of the treatment plan.
B. Educate the client about the need for antibiotics. If an infection is present, antibiotics may be necessary. It’s important for the client to understand the purpose and proper use of these medications.
C. Consult a nutritionist for a diet plan. Good nutrition is essential for wound healing. Certain nutrients, like protein, vitamin C, and zinc, can promote wound healing.
D. Remove any non-viable tissue. Debridement, or the removal of dead (non-viable) tissue, can help promote the healing of the wound by reducing the risk of infection and allowing healthy tissue to grow.
Correct Answer is A
Explanation
A. Electrical burns can have small amounts of skin damage, but more extensive damage beneath the skin.
This response is the best choice because it educates the client about the potential for deeper tissue damage associated with electrical burns. It acknowledges that while the burn on the skin may appear small, the damage underneath could be more extensive, affecting muscles, nerves, and blood vessels.
B. Electrical burns commonly cause reddened/purplish skin without blistering.
This statement is not the best response because it focuses solely on the appearance of the skin without addressing the potential for deeper tissue damage. While it is true that electrical burns can present with reddened or purplish skin without blistering, this response does not provide comprehensive information about the nature and severity of electrical burns.
C. Electrical burns typically are minor.
This response is incorrect because it downplays the seriousness of electrical burns. While some electrical burns may indeed be minor, others can cause significant tissue damage and complications. It's important for the nurse to educate the client about the range of severity that electrical burns can present.
D. Electrical burns usually cause much more skin damage than what can be seen on your skin.
This statement is partially accurate but does not provide as much information as choice A. While it acknowledges that electrical burns can cause more damage than what is visible on the skin's surface, it doesn't emphasize the potential for deeper tissue damage as effectively as choice A does.
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