A 45-year-old client receives treatment for an acute issue in the urgent care clinic.
The nurse assesses the client's concerns, documents findings, and evaluates vital signs and initial laboratory results. Which client cues are most concerning? Select all that apply.
Wound drainage.
Platelet count.
Subjective report of fatigue.
White blood cells.
Client allergies.
Blood pressure.
C-reactive protein.
Temperature.
Pain rating.
Wound appearance.
Correct Answer : A,D,G,H,J
Choice A rationale
Purulent or excessive drainage from a wound is a critical cue indicating localized infection or impaired healing. In this client, the presence of drainage suggests the body is actively battling pathogens or trying to manage tissue necrosis. This finding must be monitored closely to prevent the progression to systemic sepsis. The character of the drainage, such as color and odor, provides essential information regarding the type of bacteria and the severity of the underlying inflammatory process.
Choice B rationale
The platelet count of 375,000/uL is marginally elevated above the standard reference range of 150,000 to 350,000/uL. While this can occur in response to inflammation or stress, it is not a primary concern or a specific indicator of acute danger for this patient. This mild thrombocytosis is generally considered a secondary or reactive finding and does not require urgent intervention or represent a high-priority clinical cue compared to signs of active infection or sepsis.
Choice C rationale
Fatigue is a common and non-specific symptom that can be associated with chronic illness, anemia, or the general metabolic demands of healing a chronic wound. While it is important to note, it does not provide specific diagnostic utility for acute infection or immediate physiological instability. In a patient with a chronic lower leg wound, fatigue is expected and is less concerning than objective clinical data like elevated white blood cell counts or systemic inflammatory markers.
Choice D rationale
A white blood cell count of 16,500/uL is significantly higher than the normal reference range of 4,000 to 10,000/uL. This leukocytosis is a major clinical cue signifying that the body is mounting an immune response to an infection or severe tissue injury. In the context of a chronic wound, such an elevation suggests that the infection is no longer localized and may be spreading, necessitating immediate further diagnostic evaluation and potentially more aggressive antibiotic therapy.
Choice E rationale
Documenting client allergies is a standard part of the nursing assessment and is vital for safety, particularly before administering new medications. However, in the context of identifying cues most concerning for the current acute issue, an allergy list is a baseline safety parameter rather than an active indicator of the patient's physiological status or the severity of their wound infection. It does not provide information about the current inflammatory or infectious state of the client.
Choice F rationale
Blood pressure is a key vital sign used to monitor hemodynamics. While it is important to monitor for signs of septic shock, such as hypotension, there is no indication in the data provided that the blood pressure is currently outside of the normal range or a primary concern. Until the blood pressure shows a significant deviation from baseline, it remains a routine monitoring parameter rather than a prioritized cue indicating an acute change in the client's infectious status.
Choice G rationale
The C-reactive protein level of 15 mg/dL is above the normal threshold of less than 10 mg/dL. This is a concerning cue because it is a sensitive biochemical marker of systemic inflammation. Elevated levels indicate that the wound is causing a significant inflammatory response within the body. Tracking this level helps clinicians evaluate the effectiveness of treatment, as the protein has a short half-life and will decrease rapidly once the inflammatory stimulus or infection is successfully controlled.
Choice H rationale
An elevated temperature is a systemic manifestation of the inflammatory response and is often triggered by pyrogens during an infection. It is a highly concerning cue as it indicates that the localized wound infection may be progressing to a systemic level. Fever increases the metabolic rate and oxygen consumption of tissues, which can be detrimental to a patient already struggling with wound healing. Monitoring temperature is essential for early detection of potential sepsis and systemic involvement.
Choice I rationale
While a pain rating is an important part of a comprehensive assessment, it is subjective and can be influenced by many factors, including the patient's previous experiences and pain tolerance. In chronic wound care, pain may be constant or related to dressing changes. While it must be managed for the client's comfort, it is generally considered less concerning than objective laboratory findings and physical cues that point directly to the presence of an acute and potentially dangerous infection.
Choice J rationale
The appearance of the wound, including redness, warmth, swelling, and the presence of necrotic tissue or purulent drainage, provides direct evidence of the local tissue environment. Changes in wound appearance are primary cues for diagnosing infection and determining the need for intervention. A wound that looks moist, red, or foul-smelling indicates active bacterial colonization and tissue breakdown, making it a high-priority cue that requires immediate attention from the healthcare team to prevent further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Pyuria refers to the presence of white blood cells or pus in the urine, which typically indicates an underlying urinary tract infection or inflammatory process. Normal urine should be clear and generally free of significant leukocyte counts, usually less than 2 to 5 white blood cells per high power field. Pyuria is a qualitative description of urine content rather than a quantitative measure of the total volume produced by the kidneys over a twenty-four-hour period.
Choice B rationale
Anuria is defined as a total urine output of less than 50 mL or 100 mL in a 24-hour period, often signifying complete kidney failure or a major obstructive event. In a healthy adult, the kidneys should produce significantly more, with a normal 24-hour output ranging between 800 and 2000 mL depending on fluid intake. Anuria is a critical clinical finding that requires immediate medical intervention to address the cessation of waste excretion and fluid balance.
Choice C rationale
Oliguria is characterized by a diminished capacity to produce urine, typically defined as an output of less than 400 mL but more than 100 mL over 24 hours in an adult. While it indicates significant renal impairment or dehydration, it is not as severe as anuria. Normal kidney function involves filtering the entire blood volume many times a day, and an output falling below 400 mL suggests the kidneys cannot effectively clear metabolic waste products.
Choice D rationale
Glycosuria is the medical term for the excretion of glucose in the urine, which commonly occurs when blood glucose levels exceed the renal threshold of approximately 180 mg/dL. In a healthy individual, the urine should contain no glucose because the kidneys reabsorb it back into the bloodstream. Like pyuria, glycosuria describes the chemical composition of the urine rather than the total volume produced, making it irrelevant to the specific definition of low urine output levels.
Correct Answer is C
Explanation
Choice A rationale
Purulent drainage is thick and opaque, often appearing yellow, green, or brown. It is primarily composed of dead debris, inflammatory cells, and live or dead bacteria. The presence of purulent discharge is a hallmark sign of infection within the wound bed. Because the client's drainage is described as clear, thin, and watery, it does not meet the criteria for purulent material, which indicates a more significant inflammatory and infectious response.
Choice B rationale
Serosanguineous drainage is a mixture of serum and red blood cells, resulting in a pale red or pinkish fluid that is thin and watery. It is commonly seen in the early stages of wound healing or after surgical dressing changes. While it shares the thin consistency described, the presence of a pink or red tint distinguishes it from purely clear fluid. Therefore, it does not accurately describe the clear drainage noted in this assessment.
Choice C rationale
Serous drainage is the clear, yellowish, or thin watery part of the blood that is left over after the cells and clotting factors have been removed. It is a normal finding during the inflammatory stage of wound healing and represents the leakage of plasma from capillaries into the interstitial space. It is characterized by its lack of color and low viscosity, which perfectly matches the nurse's observation of a clear and watery wound output.
Choice D rationale
Sanguineous drainage consists of large amounts of red blood cells and looks like bright red or dark red blood. This type of drainage indicates fresh bleeding from the wound site, which may occur immediately after an injury or surgery. Since the description provided specifies that the fluid is clear and watery, it cannot be documented as sanguineous, as the latter requires the visible presence of whole blood and a deep red color.
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