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 D
Explanation
Choice A reason: Metabolic acidosis is characterized by a decrease in blood pH (less than 7.35) due to a primary decrease in bicarbonate (HCO₃). The arterial blood gas results in this scenario do not indicate metabolic acidosis, as the pH is elevated and HCO₃ is within the normal range.
Choice B reason: Metabolic alkalosis is characterized by an increase in blood pH (greater than 7.45) due to a primary increase in bicarbonate (HCO₃). In this case, the pH is indeed elevated, but the bicarbonate level is normal, making this condition unlikely.
Choice C reason: Respiratory acidosis is characterized by a decrease in blood pH (less than 7.35) due to a primary increase in PaCO₂. The arterial blood gas results show an elevated pH and a decreased PaCO₂, which are not consistent with respiratory acidosis.
Choice D reason: Respiratory alkalosis is characterized by an increase in blood pH (greater than 7.45) due to a primary decrease in PaCO₂. In this scenario, the pH is elevated at 7.48, and the PaCO₂ is decreased at 32 mm Hg, indicating respiratory alkalosis. The bicarbonate level is within the normal range, further supporting this interpretation.
Correct Answer is B
Explanation
Choice A reason: Checking the patient's temperature is important for assessing the severity of the pneumonia and monitoring for fever, but it is not the priority action before administering the first dose of vancomycin.
Choice B reason: Obtaining sputum cultures is the priority action because it allows for the identification of the causative organism and determination of its antibiotic susceptibility. This helps ensure that the prescribed antibiotic is appropriate for the patient's infection. Cultures should be obtained before starting antibiotic therapy to avoid interference with culture results.
Choice C reason: Checking the patient's blood pressure is important for overall patient assessment and monitoring, especially considering potential side effects of vancomycin. However, it is not the primary action needed before the first dose of the antibiotic.
Choice D reason: Drawing a blood specimen to evaluate the white blood cell count is useful for assessing the severity of the infection and the patient's immune response. However, this can be done after obtaining the sputum cultures and is not the immediate priority before administering the antibiotic.
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.