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: Observing chest wall shape assesses for abnormalities like barrel chest, not tactile fremitus. Fremitus involves feeling vocal vibrations, increased in pneumonia due to consolidated lung tissue. Visual inspection does not evaluate vibration transmission, making it irrelevant for assessing fremitus in suspected pneumonia.

Choice B reason: Tactile fremitus is assessed by placing the palm on the chest while the client speaks, feeling vibrations through consolidated lung tissue in pneumonia. Fluid-filled alveoli enhance sound transmission, increasing fremitus. This directly evaluates lung pathology, confirming consolidation, critical for diagnosing pneumonia’s extent and severity.

Choice C reason: Using a stethoscope assesses breathing sounds like crackles, not tactile fremitus, which requires palpation of vocal vibrations. While breath sounds aid pneumonia diagnosis, fremitus specifically evaluates consolidation via vibration, making stethoscope use incorrect for this physical assessment technique focused on lung tissue density.

Choice D reason: Compressing tissue for crackling assesses crepitus or subcutaneous emphysema, not fremitus. In pneumonia, fremitus increases due to consolidation, not tissue compression. This method is irrelevant, as fremitus relies on vocal vibration transmission through palpation, making it inappropriate for assessing pneumonia-related lung changes.

A. Red blood cell count of 3.5 x 10⁶/µL (3.5 x 10¹²/L). B. White blood cell count of 1,500/mm³ (1.5 x 10⁹/L). C. Hematocrit of 33% (0.33 volume fraction). D. Hemoglobin of 10 g/dL (6.21 mmol/L).

Correct Answer is B

Explanation

Choice A reason: A red blood cell count of 3.5 x 10⁶/µL indicates anemia from myelosuppression, reducing oxygen transport. RBCs do not fight infection, so this does not support “risk for infection.” Low WBCs impair immune defense, increasing infection susceptibility, making WBC count more relevant to the nursing problem in this context.

Choice B reason: A WBC count of 1,500/mm³ indicates severe leukopenia from myelosuppression, reducing neutrophil production. This impairs immune response, significantly raising infection risk, as pathogens overwhelm the body’s defenses. This lab value directly supports “risk for infection,” necessitating precautions like isolation or antibiotics to prevent opportunistic infections.

Choice C reason: Hematocrit of 33% reflects anemia in myelosuppression, lowering oxygen delivery. This causes fatigue but does not increase infection risk, as RBCs are not immune cells. WBCs, particularly neutrophils, are critical for infection defense, making low WBC count more relevant to the nursing problem than hematocrit.

Choice D reason: Hemoglobin of 10 g/dL indicates anemia, reducing oxygen-carrying capacity in myelosuppression. This does not directly increase infection risk, as hemoglobin is not involved in immunity. Low WBCs compromise pathogen defense, making WBC count the key value supporting “risk for infection” in this client’s care plan.

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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

In assessing tactile fremitus in the client with suspected pneumonia, the nurse should perform which action?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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