The nurse assesses a wound with exudate. What should be included when documenting the exudate? (Select all that apply.)
Color
Odor
Heat
Consistency
Amount
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Stage 1 is a wound that involves only the epidermis, the outermost layer of the skin. It appears as a nonblanchable redness, warmth, or hardness on intact skin. It does not have any breakage or ulceration of the skin.
Choice B reason: Stage 2 is a wound that involves the epidermis and the dermis, the second layer of the skin. It appears as a shallow, open, reddened ulcer with a partialthickness loss of skin. It may have some serous exudate, but no slough or eschar. It may also present as a blister or abrasion.
Choice C reason: Stage 3 is a wound that involves the epidermis, the dermis, and the subcutaneous tissue, the third layer of the skin. It appears as a deep, open, reddened ulcer with a fullthickness loss of skin. It may have some slough or eschar, but no exposed bone, tendon, or muscle. It may also have tunneling or undermining of the wound edges.
Choice D reason: Stage 4 is a wound that involves the epidermis, the dermis, the subcutaneous tissue, and the underlying structures, such as bone, tendon, or muscle. It appears as a deep, open, reddened ulcer with a fullthickness loss of skin and tissue. It has exposed bone, tendon, or muscle, which may be visible or palpable. It may also have slough, eschar, necrosis, infection, or osteomyelitis.
Correct Answer is C
Explanation
Choice A reason: Send the client back to surgery is not the nurse's next action, because it is premature and inappropriate. Sending the client back to surgery requires a medical order and a clear indication of the need for surgical intervention. The nurse cannot make this decision without first assessing the wound and contacting the provider.
Choice B reason: Call the provider immediately is not the nurse's next action, because it is not the most urgent and relevant. Calling the provider immediately is an important action, but it should be done after assessing the wound and gathering the necessary data. The nurse should be able to report the findings of the wound assessment, such as the size, shape, color, amount, and type of drainage, as well as the vital signs, pain level, and mental status of the client.
Choice C reason: Assess the wound for signs of dehiscence is the nurse's next action, because it is the most urgent and relevant. Assessing the wound for signs of dehiscence is a priority action, because it can identify the cause and severity of the problem. Dehiscence is a complication that occurs when the surgical incision splits open or separates, which can cause increased drainage, pain, and infection. Dehiscence can be caused by factors such as infection, poor wound healing, excessive strain, or trauma. Dehiscence can be detected by inspecting the wound for gaps, edges, or protrusions.
Choice D reason: Prepare to culture the wound is not the nurse's next action, because it is not the most urgent and relevant. Preparing to culture the wound is a possible action, but it should be done after assessing the wound and contacting the provider. Culturing the wound is a procedure that involves collecting a sample of the wound drainage and sending it to the laboratory for analysis, which can help identify the type and source of infection. Culturing the wound requires a medical order and a sterile technique.
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