When changing the client's dressing for a vacuum-assisted closure (VAC) wound therapy system, the nurse observes foul, purulent drainage.
Which intervention(s) should the nurse implement? Select all that apply.

Document the wound measurements with tunneling.

Cleanse the wound and discontinue the VAC system.

Increase the wound VAC suction to eliminate the drainage.

Consult the wound care specialist to evaluate the wound.

Reapply the VAC system after irrigating away drainage.

Answer and Explanation

Correct Answer : A,B,D

Choice A rationale

Documenting the wound measurements with tunneling is important for tracking the wound's progression and planning appropriate interventions. Accurate documentation helps in assessing the effectiveness of the treatment plan.

Choice B rationale

Cleansing the wound and discontinuing the VAC system is necessary when foul, purulent drainage is observed. This action helps to prevent further infection and allows the healthcare provider to reassess the wound care approach.

Choice D rationale

Consulting the wound care specialist to evaluate the wound is essential for expert advice on managing complex wounds. Specialists can provide tailored recommendations to promote wound healing and prevent complications.

Choice C rationale

Increasing the wound VAC suction to eliminate the drainage is not appropriate as it may worsen the infection or damage the surrounding tissues. Proper wound care protocols should be followed to ensure safe and effective treatment.

Choice E rationale

Reapplying the VAC system after irrigating away drainage is not advisable if there is evidence of infection. The wound should be thoroughly assessed, and appropriate measures should be taken to address the underlying infection.

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"E"}

Explanation

Epidural anesthesia can cause vasodilation and a resultant drop in blood pressure, hence the importance of close monitoring and IV fluid administration to maintain blood pressure levels.

Risk Factors:

Peripheral vasodilation: This is related to the relaxation of blood vessels, which can lead to a drop in blood pressure (hypotension). It is not a direct risk on its own but a cause of hypotension.
Hypotension: This is the correct answer. Epidural anesthesia can cause a significant drop in blood pressure due to vasodilation.
Urinary retention: This can occur with epidural anesthesia as the sensation to urinate may be diminished, causing the bladder to fill and potentially lead to bladder distention and discomfort.
Fluid overload: This is less commonly associated with epidural anesthesia. It is typically related to excessive intravenous fluid administration.

Causes:

Inadequate pain relief: This would not directly cause the issues mentioned above but would indicate that the epidural is not effectively managing the client's pain.
Decreased fetal heart rate: This can be a consequence of maternal hypotension, which reduces blood flow to the placenta.
Full urinary bladder: This can be a result of urinary retention due to the effects of the epidural, but it is not a direct cause of hypotension.
Inability to push: This can occur with epidural anesthesia as it may decrease the ability to feel contractions and effectively push during delivery, but it is not related to hypotension.

Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"C"}

Explanation

Rationale for correct answer:

Pain relief: The purpose of epidural anesthesia is to provide pain relief during labor. Since the nurse’s notes state that the client is comfortable and reports adequate pain relief, it demonstrates that the epidural anesthesia is effective.
Fetal heart rate: Monitoring fetal heart rate is crucial to ensure the well-being of the baby during labor. The nurse’s notes state that the fetal heart rate is within normal limits, indicating that the epidural anesthesia has not adversely affected the baby and is working effectively.

Rationale for incorrect answers:

Good urine output: While good urine output is important, it is not a direct indicator of the effectiveness of epidural anesthesia. It does not provide information about pain relief or fetal well-being.
Vital signs: Vital signs are important to monitor but do not specifically indicate the effectiveness of epidural anesthesia in terms of pain relief and fetal well-being.
Progression of labor: The progression of labor is influenced by various factors, not just the effectiveness of epidural anesthesia. It is not a direct measure of the epidural’s effectiveness.
Labor augmentation: Labor augmentation refers to interventions to stimulate labor. It is not related to the effectiveness of epidural anesthesia.

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When changing the client's dressing for a vacuum-assisted closure (VAC) wound therapy system, the nurse observes foul, purulent drainage. Which intervention(s) should the nurse implement? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Scenario: A nurse is caring for a 26-year-old gravida 2 para 1 female client in the labor and delivery unit. Exhibits The client receiving epidural anesthesia would be at risk for developing dropdown due to dropdown.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"E"}

Explanation

A nurse is caring for a 26-year-old gravida 2 para 1 client in the labor and delivery unit. Exhibits Drag from the Word Choices to complete the sentence. The client demonstrates effective epidural anesthesia by:dropdown and dropdown

Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"C"}

Explanation

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The nurse is completing the admission assessment of a client with multiple sclerosis (MS). Which finding(s) should be reported to the healthcare provider immediately? Select all that apply.

A client expresses concern about receiving proper care in accordance with the client's religion. Which action is best for the nurse to take?

When changing the client's dressing for a vacuum-assisted closure (VAC) wound therapy system, the nurse observes foul, purulent drainage.
Which intervention(s) should the nurse implement? Select all that apply.