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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Hemoglobin (Hgb) and Hematocrit (Hct) are important indicators of anemia, which can be caused by nutritional deficiencies such as iron, vitamin B12, or folate deficiencies. For an older adult female, the reference range for hemoglobin is 12 to 16 g/dL, and the hematocrit range is 37% to 47%. A hemoglobin of 11.8 g/dL and a hematocrit of 34% are below the normal range, indicating potential anemia, which could be related to nutritional deficiencies.
B. Weight loss or being underweight can be a sign of nutritional deficiency, particularly if it is unintentional. However, this option lacks specific details about the extent of weight loss and its relation to other indicators. Weight alone does not provide complete information about nutritional deficiencies without additional context, such as changes in weight over time or body composition.
C. A decrease in lean body mass can be indicative of malnutrition or a prolonged deficiency in protein or overall caloric intake. While it is an important indicator of nutritional status, it reflects long-term changes and may not immediately show acute deficiencies.
D. Serum albumin and serum transferrin are biomarkers of nutritional status. The reference range for serum albumin is 3.5 to 5.0 g/dL, and for serum transferrin, it is 250 to 380 mg/dL. A serum albumin level of 3 g/dL and a serum transferrin level of 180 mg/dL are both below the normal range, indicating possible malnutrition or protein deficiency.

A. Develop self-awareness of the nurse's personal values to avoid imposing these values on the client. B. Listen to the ethics committee discussions and then inform the client what actions should be taken. C. Challenge members of the healthcare team whose opinions differ from the wishes of the client. D. Educate the client about current nursing literature findings related to the client's ethical dilemma.

Correct Answer is A

Explanation

A. Developing self-awareness of personal values is crucial for a nurse acting as an advocate. It ensures
that the nurse’s own beliefs and biases do not interfere with representing the client's wishes and values. This self-awareness helps the nurse advocate effectively for the client’s preferences and decisions without imposing their own personal values.
B. While listening to the ethics committee discussions is important for understanding the context of the ethical dilemma, informing the client about what actions should be taken might not align with the nurse’s role as an advocate. The nurse's role is to represent the client's wishes and interests, not to dictate actions based on the committee’s deliberations.
C. It is important to ensure the client’s wishes are represented, but challenging team members should be done respectfully and constructively. The nurse should focus on presenting the client’s viewpoint clearly and facilitating a discussion that considers the client’s preferences.
D. Educating the client about current literature can be helpful, but it is not the primary responsibility of the nurse in the role of an advocate at an ethics committee meeting. The nurse’s primary role is to
represent the client’s wishes and ensure their voice is heard in the ethical decision-making process.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The nurse has agreed to serve as a client's advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the client. To successfully represent the client, what action is essential for the nurse to take?

Correct Answer is A

Explanation

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