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

Answer and Explanation

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.

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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.

A. Type 2 diabetes mellitus B. Alcohol abuse C. Anxiety D. Impaired communication

Correct Answer is B

Explanation

Choice A reason: Type 2 diabetes mellitus, while a serious chronic condition, does not directly predispose patients to delirium. Diabetes primarily impacts the body's ability to regulate blood glucose levels, leading to complications such as cardiovascular disease, neuropathy, and nephropathy. However, it is not directly linked to the acute cognitive disturbances seen in delirium unless it leads to severe metabolic derangements, which is less common.

Choice B reason: Alcohol abuse is a significant risk factor for the development of delirium, especially in ICU patients. Chronic alcohol use can lead to a condition known as delirium tremens (DTs) during withdrawal, characterized by severe agitation, confusion, hallucinations, and autonomic hyperactivity. Patients with a history of alcohol abuse may have altered brain chemistry and neurotransmitter imbalances that predispose them to delirium when stressed by illness or surgery. Moreover, alcohol abuse can lead to liver dysfunction, nutritional deficiencies (particularly thiamine), and other systemic issues that further exacerbate the risk.

Choice C reason: Anxiety can exacerbate stress and discomfort in a patient but is not a primary causative factor for delirium. Anxiety may contribute to an increased sense of fear or confusion, especially in an ICU setting. However, it does not cause the profound disruption in cognitive function, attention, and awareness that characterizes delirium.

Choice D reason: Impaired communication might be a consequence or symptom seen in patients with delirium, but it is not a root cause. Patients with pre-existing communication difficulties might struggle more to express symptoms or needs, which could complicate care, but it does not inherently lead to the onset of delirium. Effective communication strategies and aids can help manage these challenges but do not address the underlying neurological changes seen in delirium.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with diabetes is starting on insulin therapy. Which type of insulin will the nurse discuss using for mealtime coverage?

Correct Answer is C

Explanation

Which patient problem is a significant risk factor for the development of delirium in the intensive care unit (ICU)?

Correct Answer is B

Explanation

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