While changing the dressing of a client who is immobile, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?
C-reactive protein level.
Culture for sensitive organisms.
Serum albumin.
Serum blood glucose (BG) level.
The Correct Answer is B
A. CRP is an acute-phase protein produced by the liver in response to inflammation. Elevated CRP levels indicate systemic inflammation or infection. Measuring the CRP level can help confirm the presence of an inflammatory process, such as infection, and monitor the severity of inflammation. However, while useful, CRP alone might not provide the complete picture needed for specific wound management.
B. Culturing the wound for sensitive organisms is crucial when an infection is suspected. This test will identify the specific bacteria or other pathogens causing the infection and determine their sensitivity to various antibiotics. This information is essential for choosing the appropriate treatment to address the infection effectively.
C. Serum albumin levels provide information about the client’s nutritional status and can reflect protein malnutrition. Low serum albumin levels can indicate poor wound healing due to inadequate protein levels, which affects tissue repair. While serum albumin is important for understanding overall nutritional status, it does not directly diagnose or confirm infection.
D. Blood glucose levels are important to monitor, especially in diabetic patients, as high blood glucose can impair wound healing and increase the risk of infections. However, blood glucose levels are more related to the client's ability to heal rather than directly identifying or managing an infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. CRP is an acute-phase protein produced by the liver in response to inflammation. Elevated CRP levels indicate systemic inflammation or infection. Measuring the CRP level can help confirm the presence of an inflammatory process, such as infection, and monitor the severity of inflammation. However, while useful, CRP alone might not provide the complete picture needed for specific wound management.
B. Culturing the wound for sensitive organisms is crucial when an infection is suspected. This test will identify the specific bacteria or other pathogens causing the infection and determine their sensitivity to various antibiotics. This information is essential for choosing the appropriate treatment to address the infection effectively.
C. Serum albumin levels provide information about the client’s nutritional status and can reflect protein malnutrition. Low serum albumin levels can indicate poor wound healing due to inadequate protein levels, which affects tissue repair. While serum albumin is important for understanding overall nutritional status, it does not directly diagnose or confirm infection.
D. Blood glucose levels are important to monitor, especially in diabetic patients, as high blood glucose can impair wound healing and increase the risk of infections. However, blood glucose levels are more related to the client's ability to heal rather than directly identifying or managing an infection.
Correct Answer is A
Explanation
A. The development of a fever and dyspnea in a client receiving continuous tube feeding could indicate a serious complication, such as aspiration pneumonia, infection, or another significant issue. Reporting these findings to the healthcare provider is crucial for further assessment, diagnosis, and intervention.
B. While monitoring electrolyte values is important in clients receiving tube feedings, especially if there are concerns about dehydration or imbalances, it is not the immediate priority in this scenario. The client's fever and dyspnea suggest an acute issue that needs prompt attention, and addressing the acute symptoms and reporting them to the healthcare provider takes precedence over reviewing electrolytes.
C. An incentive spirometer is useful for improving lung function and preventing atelectasis, particularly in postoperative or immobile patients. However, the presence of fever and dyspnea could indicate a more urgent problem such as aspiration or infection, which requires immediate medical evaluation and intervention.
D. Connecting the tube to low intermittent suction is typically used to decompress the stomach in cases of gastric distension or to prevent aspiration of gastrointestinal contents. However, in the context of the client's new onset of fever and dyspnea, this action does not directly address the potential underlying cause, which could be more serious.
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