While changing the dressing of a client who is immobile, the practical nurse (PN) 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 PN should evaluate 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
The correct answer is choice B. Culture for sensitive organisms.
Choice A rationale:
C-reactive protein (CRP) levels are indicative of inflammation in the body and can help identify the presence of an infection. However, CRP levels do not provide specific information about the type of organism causing the infection, which is crucial for targeted treatment.
Choice B rationale:
A culture for sensitive organisms is essential in this scenario because it identifies the specific bacteria or other pathogens present in the wound. This information is critical for selecting the appropriate antibiotic therapy to treat the infection effectively.
Choice C rationale:
Serum albumin levels are important for assessing nutritional status and overall health, which can impact wound healing. Low albumin levels can indicate poor nutritional status and delayed wound healing, but they do not provide immediate information about the infection itself.
Choice D rationale:
Serum blood glucose (BG) levels are crucial for managing diabetes and can affect wound healing. High blood glucose levels can impair the immune response and slow down the healing process. However, like CRP, BG levels do not provide specific information about the type of infection present in the wound.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Determine the client's usual bowel pattern.
Choice A rationale:
Administering a prescribed PRN stool softener may be necessary if the client is experiencing constipation, but it is not the first action the PN should implement. Before administering any medication, the PN should gather more information to make an informed decision.
Choice B rationale:
Encouraging the client to ambulate more frequently can be beneficial for promoting bowel movements, but it is not the first action to implement. The PN should first assess the client's bowel pattern to determine if there is a deviation from their usual routine.
Choice C rationale:
Recommending increasing high fiber foods daily can also help with constipation, but it is not the first action to take. The PN should assess the client's current bowel pattern to better understand the situation.
Choice D rationale:
Determining the client's usual bowel pattern is the first action the PN should take. This assessment will help establish a baseline and identify any deviations that might indicate a potential issue, which can then guide further interventions.
Correct Answer is A
Explanation
This is the most important follow-up assessment for the PN to implement because it can detect signs of bleeding, infection, or shock that may result from the unsecured surgical dressing. The PN should monitor the client's blood pressure, pulse, temperature, and respiratory rate and report any abnormal changes.
B. Fluid volume intake and output is not the most important follow-up assessment for this client and may not reflect the current status of the client's fluid balance or blood loss.
C. Volume of peripheral pulses is not the most important follow-up assessment for this client and may not be affected by the unsecured surgical dressing unless it is located on a limb or near a major artery.
D. Incisional pain scale rating is not the most important follow-up assessment for this client and may not indicate the severity or cause of the client's pain.
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