Which action should the nurse take after assessing a 2-day-old wound that has a crust along the edges, is red and appears slightly swollen?
Apply warm soaks to reduce the inflammation.
Notify the health care provider immediately of the infection.
Place the client on contact (wound) precautions.
Document the findings and continue to monitor the wound.
The Correct Answer is D
. Document the findings and continue to monitor the wound. This is because a 2-day-old wound that has a crust along the edges, is red and appears slightly swollen is likely in the inflammatory phase of wound healing. This phase is characterized by hemostasis, chemotaxis, and increased vascular permeability, which can
cause redness and swelling. The crust along the edges is formed by the clotting of blood and platelets.
These are normal signs of wound healing and do not indicate infection or complications.
Choice A is wrong because applying warm soaks to reduce inflammation can interfere with the natural process of wound healing and increase the risk of infection.
Choice B is wrong because notifying the health care provider immediately of the infection is not necessary unless there are other signs of infection such as fever, pus, foul odor, or increased pain.
Choice C is wrong because placing the client on contact (wound) precautions is not required for a 2-day-old wound that is not infected or draining. Wound precautions are only indicated for wounds that are colonized or infected by multidrug-resistant organisms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The client received a dose of clopidogrel at 2200. Clopidogrel is an antiplatelet drug that increases the risk of bleeding during and after a liver biopsy. The healthcare provider should be informed of this medication and decide whether to postpone the biopsy or administer reversal agents.
Choice A is wrong because being NPO since 2300 is a standard preparation for a liver biopsy.
Choice B is wrong because pain in the left lower quadrant and constipation are not related to the liver biopsy and do not pose an immediate risk.
Choice D is wrong because having an allergy is not relevant to the liver biopsy unless it is an allergy to the local anesthetic or contrast agent used.
Correct Answer is B
Explanation
This needle size is appropriate for an intramuscular injection into the deltoid of a 175-pound adult male with a viscous fluid.
The needle length should be long enough to reach the muscle through the subcutaneous tissue, and the needle gauge should be suitable for the viscosity of the fluid. A 23-gauge needle is a common choice for intramuscular injections.
Choice A is wrong because a 1/2 inch needle is too short to reach the deltoid muscle in an adult male.
Choice C is wrong because a 1-1/2 inch needle is too long and may cause injury to the underlying nerves or blood vessels.
Choice D is wrong because a 16-gauge needle is too large and may cause excessive tissue trauma and pain.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today