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 B

Explanation

Choice A reason: Urine output of 30 mL/hr is concerning as it is on the lower end of normal and can indicate dehydration or impaired renal function. However, in this context, it is less immediately alarming compared to severely low blood pressure.

Choice B reason: Blood pressure of 90/40 is critically low and indicates hypotension, which can be a sign of severe dehydration or shock, especially in a patient with ongoing nausea and vomiting. This requires immediate attention and intervention to stabilize the patient and prevent further complications.

Choice C reason: An infiltrated IV site is a problem that needs to be addressed to ensure proper administration of fluids and medications. However, it is not as immediately life-threatening as hypotension.

Choice D reason: Oral fluid intake of 100 mL for 8 hours is inadequate, suggesting that the patient may be dehydrated. While concerning, it is not as acutely critical as low blood pressure, which directly affects perfusion and organ function.

A. Endocardial infection B. Brain infection C. Urinary tract infection D. Pneumonia E. Gastrointestinal infection

Correct Answer is C

Explanation

Choice A reason: Endocardial infection is not commonly associated with Alzheimer's disease. While it can occur, it is not a frequent infection related to chronic dementia.

Choice B reason: Brain infections, such as encephalitis, can occur but are not among the most common infections seen in patients with Alzheimer's disease.

Choice C reason: Urinary tract infections (UTIs) are common in patients with Alzheimer's disease due to factors such as immobility, incontinence, and the use of catheters. UTIs can exacerbate confusion and other dementia-related symptoms.

Choice D reason: Pneumonia is a common and serious infection in patients with Alzheimer's disease. Due to cognitive impairment, these patients may have difficulty swallowing, leading to aspiration pneumonia. Additionally, their weakened immune systems make them more susceptible to respiratory infections.

Choice E reason: Gastrointestinal infections are not typically associated with Alzheimer's disease as a common complication. While they can occur, they are not as prevalent as UTIs and pneumonia in this patient population.

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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

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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