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 C
Explanation
Choice A reason: NPH (Humulin N) is an intermediate-acting insulin that is used to control blood sugar levels throughout the day, not specifically for mealtime coverage. It is typically administered twice a day.
Choice B reason: Detemir (Levemir) is a long-acting insulin that provides basal insulin coverage. It helps maintain blood sugar levels stable over a 24-hour period and is not intended for controlling post-meal blood sugar spikes.
Choice C reason: Lispro (Humalog) is a rapid-acting insulin used for mealtime coverage. It is designed to be taken just before or immediately after a meal to control the sudden rise in blood sugar levels that occurs after eating.
Choice D reason: Glargine (Lantus) is a long-acting insulin that provides basal insulin coverage, helping to maintain steady blood glucose levels throughout the day and night. It is not used for mealtime blood sugar control.
Correct Answer is C
Explanation
Choice A reason: Fluid volume overload is not typically associated with diabetes insipidus. Instead, patients with diabetes insipidus often experience fluid volume deficit due to excessive urine output.
Choice B reason: Hyperglycemia is not a characteristic problem of diabetes insipidus. This condition involves an imbalance in water regulation due to insufficient production or response to antidiuretic hormone (ADH), rather than issues related to blood glucose levels.
Choice C reason: Nocturia, or frequent urination at night, is a common problem in diabetes insipidus. Patients with this condition produce large amounts of dilute urine, which can lead to frequent nighttime urination.
Choice D reason: Generalized edema is not a typical problem in diabetes insipidus. Edema is more commonly associated with conditions involving fluid retention, such as heart failure or kidney disease, rather than the excessive fluid loss seen in diabetes insipidus.
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