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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
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.
Correct Answer is C
Explanation
Choice A reason: This is incorrect because it shows that the problem is not suspected, but rather the client has a desire to improve or maintain a level of health. A wellness nursing diagnosis describes a potential or actual health state that can be enhanced.
Choice B reason: This is incorrect because it shows that the problem is not suspected, but rather the client has a cluster of related problems that are associated with a specific situation or event. A syndrome nursing diagnosis describes a patern of responses that are linked by a common cause.
Choice C reason: This is correct because it shows that the problem is suspected, but lacks enough data to support it. A ‘risk for’ nursing diagnosis describes a potential problem that may occur if certain risk factors are present.
Choice D reason: This is incorrect because it shows that the problem is not suspected, but rather the client has signs and symptoms that indicate an actual health issue. An actual nursing diagnosis describes a current problem that has been validated by data.
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