The nurse is caring for a client with a wound from a biking accident. She assesses the wound and notices that the surrounding skin is very red and warm. The wound looks swollen and is draining a green like drainage. The nurse would recognize these symptoms would be a sign of what?

Anemia

Infection

Wound healing

Necrosis

Answer and Explanation

The Correct Answer is B

Choice A rationale: Redness, warmth, swelling, and green drainage are not typically signs of anemia.
Choice B rationale: These symptoms are indicative of infection. Infections can cause localized redness, warmth, swelling, and the drainage of discolored material.
Choice C rationale: While wound healing may involve some inflammation, the described symptoms are more consistent with infection than normal wound healing.
Choice D rationale: Necrosis involves tissue death and is not typically associated with redness, warmth, and swelling.

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Correct Answer is A

Explanation

Choice A rationale: Performing hand hygiene before any wound care procedure is essential to prevent infection and maintain aseptic technique.
Choice B rationale: Assessing the condition of the visible wound bed is an important step but not the first action. Hand hygiene should precede any assessment or intervention.
Choice C rationale: Measuring the width of the wound with a disposable ruler is part of the wound measurement process but should follow hand hygiene.
Choice D rationale: Inserting a swab into the wound at 90 degrees is not the first step. Hand hygiene and assessment should precede any invasive procedures.

A. percussion. B. deep palpation. C. auscultation. D. light palpation.

Correct Answer is C

Explanation

Choice A rationale: Percussion is typically performed after auscultation in the abdominal assessment sequence.
Choice B rationale: Deep palpation is usually performed after light palpation in the abdominal assessment sequence.
Choice C rationale: Auscultation is the next step in the abdominal assessment sequence after inspection. Assessing bowel sounds is crucial before moving on to other assessment techniques.
Choice D rationale: Light palpation is often the initial step in the abdominal assessment sequence, followed by auscultation.

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The nurse is caring for a client with a wound from a biking accident. She assesses the wound and notices that the surrounding skin is very red and warm. The wound looks swollen and is draining a green like drainage. The nurse would recognize these symptoms would be a sign of what?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When measuring the size, depth, and wound tunneling of a client's stage 4 pressure injury, what action should the nurse perform first?

Correct Answer is A

Explanation

During the inspection of a client's abdomen, the nurse notes that it is visibly distended. The nurse should proceed with the client's abdominal assessment by next performing:

Correct Answer is C

Explanation

A nurse is initiating a 24-hour urine collection for a client at home. What will be the first thing the nurse will ask the client to do at the beginning of the specimen collection?

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A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (Select All that Apply.)

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