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 B
Explanation
“I apologize for not hearing you say that. Is there a better day for you?”.
This response shows empathy and respect for the client’s feelings and preferences.
It also invites the client to collaborate on finding a solution that works for both parties. Choice A is wrong because it is rude and defensive.
It does not acknowledge the client’s frustration or offer any alternatives. Choice C is wrong because it is dismissive and paternalistic.
It does not respect the client’s autonomy or consider the client’s reasons for not being able to come back on Friday.
Choice D is wrong because it is persuasive and manipulative.
It does not address the client’s concerns or explore other options.
The nurse-client relationship is based on trust, respect, and collaboration.
The nurse should use therapeutic communication skills to maintain a positive rapport with the client and promote their health and well-being.
Correct Answer is D
Explanation
Take this medication at least 30 minutes before ingesting any food or medication.
This is because alendronate (Fosamax) is a bisphosphonate that works by inhibiting the breakdown and reabsorption of bone. However, it has a very low bioavailability, which means that only a small amount of the drug is absorbed into the bloodstream when taken orally. Therefore, taking it with food or other medications can interfere with its absorption and reduce its effectiveness.
The other choices are wrong because:
A. Chew the tablet well and report any difficulty swallowing. This is wrong because alendronate tablets should not be chewed or crushed, but swallowed whole with a full glass of plain water. Chewing or crushing the tablets can increase the risk of irritation or damage to the esophagus (the tube that connects the mouth to the stomach). Difficulty swallowing is a possible side effect of alendronate and should be reported to the doctor, but it is not an instruction for taking the medication.
B. Take the medication with six to eight ounces of milk. This is wrong because milk contains calcium, which can bind to alendronate and prevent its absorption. Alendronate should not be taken with any beverages other than plain water.
C. Lie down for 15 to 30 minutes after taking the medication. This is wrong because lying down after taking alendronate can increase the risk of esophageal irritation or
ulceration. Alendronate should be taken in the morning, at least 30 minutes before eating or drinking anything, and the person should remain upright (sitting or standing) for at least 30 minutes after taking it.
Normal ranges for bone density are expressed as T-scores, which compare a person’s bone density to that of a healthy young adult of the same sex. A T-score of -1.0 or above is normal, a T-score between -1.0 and -2.5 indicates low bone density (osteopenia), and a T-score of -2.5 or below indicates osteoporosis.
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