The nurse assesses a wound with exudate. What should be included when documenting the exudate? (Select all that apply.)

Color

Odor

Heat

Consistency

Amount

Answer and Explanation

Correct Answer : A,B,D,E

Choice A reason: Color is a characteristic of exudate that should be included when documenting it. Color can indicate the type and severity of the wound infection or inflammation. For example, yellow or green exudate may indicate a bacterial infection, while red or brown exudate may indicate bleeding or necrosis.

Choice B reason: Odor is a characteristic of exudate that should be included when documenting it. Odor can indicate the presence and type of microorganisms in the wound. For example, a foul or putrid odor may indicate anaerobic bacteria, while a sweet or fruity odor may indicate pseudomonas.

Choice C reason: Heat is not a characteristic of exudate that should be included when documenting it. Heat is a sign of inflammation that can be assessed by palpating the skin around the wound, not by observing the exudate. Heat does not directly reflect the quality or quantity of the exudate.

Choice D reason: Consistency is a characteristic of exudate that should be included when documenting it. Consistency can indicate the viscosity and composition of the exudate. For example, thin or watery exudate may indicate a serous or serosanguineous fluid, while thick or creamy exudate may indicate a purulent or fibrinous fluid.

Choice E reason: Amount is a characteristic of exudate that should be included when documenting it. Amount can indicate the extent and stage of the wound healing process. For example, a large amount of exudate may indicate a high level of inflammation or infection, while a small amount of exudate may indicate a low level of inflammation or infection.

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Correct Answer is C

Explanation

Choice A reason: Eradicating the disease is not the purpose of the medications, because osteoarthritis is a chronic and progressive condition that cannot be cured by drugs. Osteoarthritis is a degenerative joint disease that causes the breakdown of cartilage and bone, leading to pain, stiffness, and reduced mobility.

Choice B reason: Turning on the immune system is not the purpose of the medications, because osteoarthritis is not an autoimmune disease that involves the immune system attacking the joints. Osteoarthritis is a mechanical disease that involves the wear and tear of the joints due to aging, injury, or overuse.

Choice C reason: Reducing pain and inflammation is the purpose of the medications, because osteoarthritis is a painful and inflammatory condition that affects the quality of life of the client. The medications for osteoarthritis include analgesics, such as acetaminophen or opioids, and antiinflammatory drugs, such as nonsteroidal antiinflammatory drugs (NSAIDs) or corticosteroids, which can relieve the symptoms and improve the function of the joints.

Choice D reason: Managing weight loss is not the purpose of the medications, because osteoarthritis is not a metabolic disease that affects the weight of the client. Osteoarthritis is a structural disease that affects the joints of the client. However, managing weight is an important factor in preventing or treating osteoarthritis, as excess weight can increase the stress and damage on the joints.

A. A client with a urinary tract infection who has a fever of 38.5°C and flank pain B. A client with a deep vein thrombosis who has a positive Homans' sign and edema in the affected leg C. A client with a myocardial infarction who has chest pain and shortness of breath D. A client with a stroke who has slurred speech and facial droop

Correct Answer is C

Explanation

Choice A reason: This is not the highest priority client because a urinary tract infection (UTI) is a common and treatable condition that affects the lower urinary system, such as the bladder or urethra. A fever of 38.5°C and flank pain can indicate that the infection has spread to the upper urinary system, such as the kidneys, which can cause pyelonephritis. Pyelonephritis is a serious but not lifethreatening complication that requires antibiotic therapy and hydration. The nurse should monitor the client's vital signs, urine output, and pain level and administer the prescribed medication and fluids.

Choice B reason: This is not the highest priority client because a deep vein thrombosis (DVT) is a blood clot that forms in a deep vein, usually in the lower extremities. A positive Homans' sign and edema in the affected leg can indicate that the clot is causing inflammation and obstruction of the blood flow. DVT is a serious but not lifethreatening complication that requires anticoagulant therapy and compression therapy. The nurse should monitor the client's vital signs, leg circumference, and pain level and administer the prescribed medication and stockings.

Choice C reason: This is the highest priority client because a myocardial infarction (MI) is a heart attack that occurs when the blood flow to a part of the heart muscle is blocked, causing tissue damage or death. Chest pain and shortness of breath can indicate that the client is experiencing acute cardiac ischemia, which can lead to cardiac arrest or heart failure. MI is a lifethreatening emergency that requires immediate intervention and treatment. The nurse should activate the rapid response team, monitor the client's vital signs, electrocardiogram, and oxygen saturation, and administer the prescribed medication and oxygen.

Choice D reason: This is not the highest priority client because a stroke is a brain attack that occurs when the blood flow to a part of the brain is interrupted, causing tissue damage or death. Slurred speech and facial droop can indicate that the client is experiencing acute neurological impairment, which can affect their communication and facial expression. Stroke is a serious but not lifethreatening complication that requires prompt evaluation and treatment. The nurse should monitor the client's vital signs, neurological status, and glucose level and administer the prescribed medication and fluids.

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The nurse assesses a wound with exudate. What should be included when documenting the exudate? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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