The nurse is changing a client’s abdominal surgical dressing. Which finding warrants notification to the healthcare provider?

Yellow purulent drainage.

Pink granulation tissue.

Serosanguineous fluid.

Approximated wound edges.

Answer and Explanation

The Correct Answer is A

Choice A reason: Yellow purulent drainage indicates wound infection, likely from bacterial proliferation (e.g., Staphylococcus aureus) causing pus. This serious complication risks delayed healing, abscess, or sepsis, necessitating provider notification for cultures, antibiotics, or surgical intervention. Infection disrupts tissue repair, requiring urgent management to prevent systemic spread or wound dehiscence.

Choice B reason: Pink granulation tissue is normal in wound healing, reflecting angiogenesis and fibroblast activity during the proliferative phase. It indicates healthy tissue formation, not requiring notification. Purulent drainage, however, signals infection, a critical issue disrupting healing and risking complications, making it the priority finding for reporting.

Choice C reason: Serosanguineous fluid, a mix of serum and blood, is expected in early surgical wounds as capillaries heal. It does not indicate infection unless excessive. Purulent drainage is more urgent, directly suggesting bacterial infection, which can lead to serious complications like sepsis, requiring immediate provider attention.

Choice D reason: Approximated wound edges indicate proper closure and healing, reducing scarring and infection risk. This positive finding does not warrant notification. Yellow purulent drainage, conversely, signals infection, a critical complication requiring urgent intervention to prevent further tissue damage or systemic infection, making it the priority.

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Correct Answer is B

Explanation

Choice A reason: Feeling guilty about drinking (CAGE’s “G”) suggests awareness of problematic use, indicating psychological dependence. However, guilt is less specific than morning drinking, as it may occur in binge or social drinking without physical addiction. Morning drinking reflects physiological dependence, a stronger marker of chronic alcoholism.

Choice B reason: Needing a morning drink (CAGE’s “E” for eye-opener) indicates physical dependence, a hallmark of alcoholism. This reflects tolerance and withdrawal, where alcohol stabilizes GABA/glutamate imbalances to prevent symptoms like tremors. It’s the most specific indicator, showing the body’s reliance on alcohol, central to alcoholism’s pathophysiology.

Choice C reason: Annoyance at drinking criticism (CAGE’s “A”) suggests defensiveness, possibly indicating psychological dependence. It’s less specific than morning drinking, reflecting social dynamics rather than physical addiction. Alcoholism involves physiological changes, and morning drinking directly demonstrates the body’s need for alcohol to manage withdrawal, making this less indicative.

Choice D reason: Feeling the need to cut down (CAGE’s “C”) shows recognition of excessive drinking but is less specific than morning drinking, which signifies physical dependence from chronic alcohol-induced neurotransmitter changes. This question captures awareness but not the physiological addiction that morning drinking indicates, central to diagnosing alcoholism.

A. Encourage the application of topical corticosteroids to eczema. B. Explain the use of chemical debridement to reduce blistering. C. Remind the client to restrict the use of heat to 15 to 20 minutes. D. Provide a sling so the left arm can be extended and elevated.

Correct Answer is A

Explanation

Choice A reason: Topical corticosteroids reduce eczema’s inflammation by inhibiting cytokines, alleviating antecubital vesicles. Heat lamps dry skin, worsening irritation and cracking. Encouraging steroids addresses the inflammatory pathophysiology, promoting healing, making this the most effective response for managing eczema and correcting harmful self-treatment.

Choice B reason: Chemical debridement is for necrotic tissue, not eczema’s inflammatory vesicles. Heat lamps exacerbate dryness, but debridement does not address immune-mediated inflammation. Corticosteroids target the cytokine-driven process, making debridement inappropriate for eczema’s pathophysiology, which requires anti-inflammatory treatment.

Choice C reason: Restricting heat to 15–20 minutes does not mitigate harm, as heat dries eczema lesions, disrupting the skin barrier and increasing infection risk. Corticosteroids reduce inflammation, addressing vesicles. Heat worsens epidermal damage, making this response ineffective compared to targeting the inflammatory cause.

Choice D reason: A sling for arm elevation is irrelevant for localized eczema, an inflammatory dermatitis, not edema requiring elevation. Heat lamps aggravate dryness, and corticosteroids treat inflammation, addressing immune-mediated pathology more effectively than positional changes, which do not impact eczema’s skin symptoms.

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The nurse is changing a client’s abdominal surgical dressing. Which finding warrants notification to the healthcare provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The CAGE questionnaire asks four questions and is a widely used tool to screen for alcoholism. Which of the four questions included in the CAGE questionnaire is most indicative of alcoholism?

Correct Answer is B

Explanation

A client newly diagnosed with eczema tells the clinic nurse of using a heat lamp to dry the fluid-filled blisters localized in the left antecubital area. How should the nurse respond?

Correct Answer is A

Explanation

Following admission for a cardiac catheterization, the nurse is providing discharge teaching to the parents of a 2-year-old toddler with Tetralogy of Fallot. Which instruction should the nurse give the parents if their child becomes pale, cool, and lethargic?

A client has a prescription for the insertion of a nasogastric tube to low intermittent suction. When inserting the nasogastric tube, the nurse observes an immediate return of “coffee ground” drainage. Which action should the nurse implement?

Which client information indicates the need for the nurse to use the CAGE questionnaire during the admission interview?

A client with gastroesophageal reflux disorder (GERD), who has been self-medicating with famotidine for the past week, is admitted to the acute care center because the symptoms have worsened. The nurse should anticipate which treatment?

On the second postoperative day, a client reports increasing abdominal pain. Assessment findings include a distended abdomen with absent bowel sounds. Which intervention should the nurse anticipate implementing?

The parents of a male infant newborn have signed an informed consent for circumcision. Which priority intervention should the nurse implement upon completion of the circumcision procedure?

The nurse orients a client with depression to a new room on the mental health unit. The client states, “It seems strange that I don’t have a television (TV) in my room.” Which statement is best for the nurse to provide?

Following a ureterolithotomy, the client has a ureteral catheter in place. Which intervention should the nurse implement?