The nurse is caring for a patient who has had a pressure injury. When assessing the wound, which finding causes the greatest concern for the nurse?
Amber fluid
Clear drainage
Purulent, draining wound
Blood-tinged fluid
The Correct Answer is C
Choice A reason: Amber fluid is typically a sign of serous exudate, which is a normal part of the inflammatory process and wound healing. It indicates the body's immune response to the injury and is generally not a cause for concern unless the volume significantly increases or changes in appearance.
Choice B reason: Clear drainage, or serous fluid, is also a normal finding in wound healing. It indicates that the wound is exuding plasma, which helps to keep the wound moist and supports the healing process. This type of drainage is typically not worrisome unless there are other signs of infection or complications.
Choice C reason: Purulent, draining wound is a major concern as it indicates the presence of pus, which is often a sign of infection. Purulent drainage can be yellow, green, or brown and is usually thick and malodorous. The presence of pus suggests that there are bacteria or other pathogens in the wound, and immediate medical intervention is necessary to prevent further complications and promote healing.
Choice D reason: Blood-tinged fluid, or serosanguinous drainage, is common in fresh wounds or after debridement. It indicates a mixture of plasma and red blood cells and can be seen in the early stages of wound healing. While it is generally not alarming, the nurse should monitor the volume and changes in the drainage to ensure there are no signs of excessive bleeding or infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Synthroid (levothyroxine) is the most commonly prescribed medication for hypothyroidism. It is a synthetic form of thyroxine (T4), which replaces the deficient hormone in patients with hypothyroidism and helps normalize their thyroid function.
Choice B reason: PTU (Propylthiouracil) is typically used for the treatment of hyperthyroidism, not hypothyroidism. It works by inhibiting the synthesis of thyroid hormones.
Choice C reason: Tapazole (methimazole) is also used for the treatment of hyperthyroidism, similar to PTU. It is not used to treat hypothyroidism.
Choice D reason: Propranolol is a beta-blocker that is used to manage symptoms of hyperthyroidism, such as tremors and palpitations. It does not treat hypothyroidism.
Correct Answer is ["A","C"]
Explanation
Choice A reason: Offering high-calorie protein snacks between meals and at bedtime is appropriate for a patient with COPD who is losing weight and eating very little. These snacks can help meet their nutritional needs and provide the extra calories and protein necessary to prevent muscle wasting and support overall health.
Choice B reason: While increasing the intake of whole grains and vegetables is generally healthy, it may not be the priority for a patient who has lost significant weight and needs to focus on higher-calorie, nutrient-dense foods. The primary goal is to address the calorie and protein deficit first.
Choice C reason: Encouraging rest before meals is beneficial as it helps conserve energy for eating. Patients with COPD often experience fatigue, which can reduce their appetite and ability to eat. Resting before meals can help them feel more energetic and better able to consume their meals.
Choice D reason: Providing a large glass of juice with each meal is not ideal for increasing calorie and protein intake. While juice can provide some calories and nutrients, it is not a good source of protein. Additionally, large volumes of liquid can create a feeling of fullness, reducing the patient's appetite for nutrient-dense foods.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.