The nurse is changing a client’s dressing. Which observation warrants immediate physician notification?

Approximated wound edges

Yellow, purulent drainage

Pink granulation tissue

Sutures in place

Answer and Explanation

The Correct Answer is A

Choice A reason: This is incorrect because it shows that the wound is healing well. Approximated wound edges mean that the edges are close together and aligned.

Choice B reason: This is correct because it shows that the wound is infected. Yellow, purulent drainage means that the wound has pus, which is a sign of inﬂammation and bacterial growth.

Choice C reason: This is incorrect because it shows that the wound is healing well. Pink granulation tissue means that the wound has new blood vessels and connective tissue, which fill the wound space and promote healing.

Choice D reason: This is incorrect because it shows that the wound is stable. Sutures in place mean that the wound has been closed with stitches, which hold the edges together and prevent bleeding.

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Correct Answer is A

Explanation

Choice A reason: “I can see you are worried.” is a therapeutic response by the PN to the family at this time. This response shows empathy, which is the ability to understand and share the feelings of another person. It also acknowledges and validates the family’s emotions, and invites them to express their concerns or fears. Therefore, this choice is correct.

Choice B reason: “Don’t worry, you have nothing to feel guilty about.” is not a therapeutic response by the PN to the family at this time. This response shows false reassurance, which is a communication technique that involves minimizing or dismissing the other person’s feelings or situation. It also implies that the family should feel guilty, and denies them the opportunity to explore their feelings or thoughts. Therefore, this choice is incorrect.

Choice C reason: “Everything possible is being done.” is not a therapeutic response by the PN to the family at this time. This response shows cliché, which is a communication technique that involves using overused or trite expressions that lack meaning or sincerity. It also avoids addressing the family’s emotions or needs, and may sound vague or insincere. Therefore, this choice is incorrect.

Choice D reason: “Let me check if you can see your loved one.” is not a therapeutic response by the PN to the family at this time. This response shows changing the subject, which is a communication technique that involves shifting the focus away from the other person’s feelings or situation. It also ignores or postpones the family’s emotional needs, and may make them feel unimportant or dismissed. Therefore, this choice is incorrect.

A. Avoid long explanations B. Ask one question at a time C. Use short sentences D. Talk loudly

Correct Answer is ["A"]

Explanation

Choice A reason: This is correct because it shows that the PN is respectful and sensitive to the client’s cognitive impairment. Long explanations can confuse and overwhelm the client, who may have difficulty processing and retaining information.

Choice B reason: This is correct because it shows that the PN is respectful and sensitive to the client’s cognitive impairment. Asking one question at a time can help the client focus and respond more easily, without feeling pressured or frustrated.

Choice C reason: This is correct because it shows that the PN is respectful and sensitive to the client’s cognitive impairment. Using short sentences can help the client understand and remember the message, without being distracted or confused by unnecessary words.

Choice D reason: This is incorrect because it shows that the PN is rude and disrespectful to the client’s hearing ability. Talking loudly can make the client feel annoyed or threatened, and may not improve communication if the client has hearing loss. The PN should talk in a normal tone and check for understanding.

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The nurse is changing a client’s dressing. Which observation warrants immediate physician notification?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is ["A"]

Explanation

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