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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?

A.

C-reactive protein level

B.

Culture for sensitive organisms.

C.

Serum albumin.

D.

Serum blood glucose (BG) level.

Answer and Explanation

The Correct Answer is B

 

The correct answer is choice B: Culture for sensitive organisms.

  • Choice A rationale:
  •  C-reactive protein level - C-reactive protein (CRP) is a blood test marker for inflammation in the body. While it could indicate an infection, it is not specific enough to identify the type of infection or the causative organism.
  •  
  • Choice B rationale:
  •  Culture for sensitive organisms - When a wound has a moderate amount of yellow and green drainage and a foul odor, it is often a sign of a bacterial infection. A culture for sensitive organisms can help identify the specific bacteria causing the infection, which is crucial for determining the most effective treatment.
  •  
  • Choice C rationale:
  •  Serum albumin - Serum albumin levels can indicate a person’s nutritional status. Low levels can slow wound healing, but they do not directly indicate the presence of an infection.
  •  
  • Choice D rationale:
  •  Serum blood glucose (BG) level - High blood glucose levels can impair the immune response and slow wound healing, making a person more susceptible to infections. However, like CRP, it does not provide information about the specific organism causing the infection.


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Related Questions

Correct Answer is D

Explanation

This comment shows empathy, respect, and support for the client, without being intrusive or judgmental. The PN acknowledges the client's feelings and offers companionship, which can help reduce isolation and loneliness.

The other options are not correct because:

A. This comment may be perceived as coercive or dismissive of the client's feelings, as it tries to persuade the client to do something he does not want to do or enjoy.

B. This comment may be perceived as accusatory or interrogatory, as it questions the client's decision or motive for staying in his room.

C. This comment may be perceived as minimizing or invalidating the client's feelings, as it implies that the client should not be sad or that his family is doing enough for him.

Correct Answer is B

Explanation

The infant has hypoglycemia, which is a low blood glucose level that can cause jitteriness, lethargy, seizures, or coma. Hypoglycemia is common in infants of mothers with gestational diabetes, as they produce excess insulin in response to high maternal glucose levels. The PN should begin frequent feedings of breast milk or formula, as this can provide a source of glucose and stimulate the infant's own glucose production.

The other options are not correct because:

A. Offering nipple feedings of 10% dextrose may be indicated in some cases of severe hypoglycemia, but it is not the first intervention. The PN should try oral feedings of breast milk or formula first, as they are more natural and less invasive.

C. Repeating the heel stick for glucose in one hour may be necessary to monitor the infant's glucose level, but it is not the first intervention. The PN should treat the hypoglycemia first, as it can have serious consequences if left untreated.

D. Assessing for signs of hypocalcemia may be important, as hypocalcemia is another possible complication in infants of mothers with gestational diabetes, but it is not the first intervention. The PN should address the hypoglycemia first, as it is more urgent and more likely to cause jitteriness.

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