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: Teaching the patient to use guided imagery can be an effective pain management strategy, but it might not be the most immediate and reassuring intervention for a patient experiencing fear about postoperative pain. This approach is more useful as an additional technique rather than the primary intervention.
Choice B reason: Describing the type of pain expected with the patient's particular surgery can provide some insight into what to anticipate, but it does not necessarily alleviate fear or provide concrete strategies for managing pain. It might even increase anxiety by focusing on the details of the pain itself.
Choice C reason: Explaining the pain management plan, including the use of a pain rating scale, is the most effective intervention. This approach directly addresses the patient's concerns by providing them with a clear understanding of how their pain will be managed and controlled postoperatively. Knowing that there is a structured plan in place, with specific methods to assess and manage pain, helps build confidence and reduces fear. The use of a pain rating scale also empowers the patient to communicate their pain levels effectively, ensuring timely and appropriate interventions.
Choice D reason: Informing the patient that pain medication will be available is helpful, but it lacks the detail and comprehensive approach of explaining the entire pain management plan. Patients may still have concerns about how their pain will be assessed and addressed specifically.
Correct Answer is C
Explanation
Choice A reason: Stage 2 pressure injuries involve partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, and moist, and may also present as an intact or ruptured serum-filled blister. Since the wound involves subcutaneous tissue, it exceeds the criteria for Stage 2.
Choice B reason: Stage 1 pressure injuries are characterized by non-blanchable erythema of intact skin. While the skin is still intact, it may appear red and not lighten when pressed. Given the description of a wound involving subcutaneous tissue, Stage 1 is not appropriate.
Choice C reason: Stage 3 pressure injuries involve full-thickness loss of skin, where adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible, but the depth of tissue damage varies by anatomical location. This aligns with the wound involving subcutaneous tissue.
Choice D reason: Stage 4 pressure injuries involve full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone. While the wound described involves subcutaneous tissue, there is no mention of deeper tissue involvement, excluding Stage 4 classification.
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