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 B

Explanation

Choice A rationale

Explaining the ELISA test for confirmation is unnecessary as the client is already confirmed HIV positive. Repeating the test may cause confusion and anxiety without offering additional benefit at this stage.

Choice B rationale

Identifying support systems in the client's life is crucial for addressing the emotional and psychological impact of being HIV positive and a victim of rape. Support systems, such as family, friends, or support groups, can provide the necessary emotional support and practical assistance to help the client cope with the challenges.

Choice C rationale

Inquiring about plans to further education may not be timely or appropriate in the context of the client's current emotional state. The priority should be addressing the client's immediate mental health needs and ensuring they have adequate support systems in place.

Choice D rationale

Exploring feelings of hope for the future is important but may not be the immediate priority. The client is currently experiencing significant emotional distress, so addressing their immediate mental health needs and ensuring support is a higher priority.

A. Oxygen saturation of 100% on 40% oxygen B. Capillary refill time of 6 seconds C. Blood pressure of 90/79 mmHg with a pulse pressure of less than 40 mmHg D. The client’s lack of urine output from the indwelling catheter

Correct Answer is ["B","C","D"]

Explanation

Choice B rationale: Capillary refill time of 6 seconds is significantly delayed and indicates poor peripheral perfusion. This finding suggests that the client may be experiencing decreased cardiac output or hypovolemia, which requires immediate attention to improve circulation and oxygen delivery to tissues.

Choice C rationale: Blood pressure of 90/79 mmHg with a pulse pressure of less than 40 mmHg is a critical finding. The narrow pulse pressure and hypotension indicate potential hypovolemia or shock, which must be addressed urgently to stabilize the client's hemodynamic status.

Choice D rationale: The client’s lack of urine output from the indwelling catheter is concerning and indicates potential kidney dysfunction or decreased renal perfusion. Immediate intervention is necessary to assess and manage potential underlying causes, such as hypovolemia or renal injury.

Choice A rationale: Oxygen saturation of 100% on 40% oxygen is not an immediate concern. While it is important to continue monitoring oxygen levels, the client is currently receiving adequate oxygenation.

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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.

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is caring for a 24-year-old female client in the post-operative unit following a horseback riding accident. Exhibits Which of the following assessment findings should the nurse attend to right away?

Correct Answer is ["B","C","D"]

Explanation

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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.