A nurse is assessing a client who has a stage 3 pressure injury. Which of the following findings indicates possible infection of the wound?
Serosanguineous drainage
Granulation tissue
Localized tenderness
Moist wound bed
The Correct Answer is C
A. Serosanguineous drainage: Serosanguineous drainage, which is a mixture of serum and blood, is common and expected in the early stages of wound healing, including stage 3 pressure injuries. It does not necessarily indicate infection.
B. Granulation tissue: Granulation tissue is a sign of healthy wound healing. It appears as red, moist tissue and indicates that the wound is healing properly, so it does not suggest infection.
C. Localized tenderness: Localized tenderness around the wound can be a sign of infection. Infection can cause pain, redness, warmth, and tenderness at the site of the pressure injury. It is important to monitor for other signs of infection, such as increased drainage or changes in wound color.
D. Moist wound bed: A moist wound bed is generally beneficial for wound healing and does not indicate infection. In fact, keeping the wound moist helps promote granulation tissue formation and wound closure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Frothy sputum: Frothy sputum, particularly pink or blood-tinged, is a classic sign of pulmonary edema, which is common in left-sided heart failure. The left side of the heart cannot pump blood effectively, leading to fluid accumulation in the lungs and causing this symptom.
B. Bradycardia: In left-sided heart failure, tachycardia (elevated heart rate) is more commonly seen as the heart tries to compensate for decreased cardiac output, not bradycardia (slow heart rate).
C. Warm skin: In left-sided heart failure, the skin may feel cool and clammy due to poor circulation and reduced cardiac output. Warm skin is not a typical finding in this condition.
D. Jugular vein distention: Jugular vein distention is more indicative of right-sided heart failure, where there is a backup of blood in the venous system. Left-sided heart failure primarily causes symptoms related to pulmonary congestion.
Correct Answer is D
Explanation
A. Perform the reconciliation only at admission and discharge: Medication reconciliation should be performed at all stages of care. It should also be done during transfers between units and at any point where medication changes occur to ensure accuracy and prevent errors.
B. Compare only the prescribed home medications to the new prescriptions: Medication reconciliation requires comparing home medications and any newly prescribed medications. This includes reviewing all medications to identify discrepancies and ensure safety.
C. Delete new prescriptions that may interact with home medications: The nurse should not delete prescriptions. Instead, they should identify potential drug interactions, assess the risks, and notify the healthcare provider to discuss alternatives or adjustments as needed.
D. Consider the risk for medication interactions: The nurse should evaluate the potential for drug interactions by comparing home medications with new prescriptions. This helps to ensure the safety and effectiveness of the client's medication regimen.
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