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

Answer and Explanation

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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Administer digoxin by IV bolus: Digoxin slows conduction through the AV node and can worsen a complete heart block. It is contraindicated in this condition and may lead to further bradycardia or cardiac arrest.
B. Prepare the client for temporary pacing:Third-degree (complete) heart block results in electrical dissociation between atria and ventricles, leading to dangerously low heart rates and inadequate perfusion. The definitive treatment is temporary pacing to stabilize the cardiac rhythm until permanent pacing can be arranged.
C. Instruct the client to perform the Valsalva maneuver: This maneuver is used to terminate supraventricular tachycardias by stimulating the vagus nerve. It is not indicated in bradyarrhythmias like third-degree heart block and could further lower the heart rate.
D. Perform carotid sinus massage: This is another vagal maneuver used to treat tachycardias, not bradycardias. Performing it in a client with third-degree heart block could dangerously reduce the heart rate further and is therefore inappropriate.

A. Oxygen saturation B. Blood pressure C. Pain level D. Hematocrit E. Temperature F. Activity level G. Breath sounds

Correct Answer is ["A","B","D","F"]

Explanation

Rationale for Correct Choices:

Oxygen saturation: The client's oxygen saturation is 94% on room air. While not critically low, given their reported shortness of breath and fatigue, this warrants follow-up. It could be indicative of the severity of their anemia impacting oxygen delivery.
Blood pressure: The client shows signs of orthostatic hypotension, with a significant drop from 132/60 mm Hg (supine) to 102/50 mm Hg (standing). This change can cause dizziness, falls, and worsened fatigue, and it may be related to anemia or volume depletion that needs evaluation.
Hematocrit: A hematocrit of 24% is critically low, indicating significant anemia. This aligns with the client’s symptoms of fatigue and dyspnea and requires prompt intervention to determine the underlying cause, such as iron or B12 deficiency.
Activity level: The client reports shortness of breath with minimal exertion and difficulty keeping up with grandchildren. This functional decline reflects impaired oxygen delivery due to anemia and must be addressed as it affects quality of life and safety.

Rationale for Incorrect Choices:

Pain level: The client reports no pain or discomfort at this time. While pain is common in rheumatoid arthritis, the current lack of pain does not require further assessment or intervention.
Temperature: The client's temperature is 37°C (98.6°F), which is normal. There are no signs of infection or inflammation requiring follow-up based solely on this vital sign.
Breath sounds: Bilateral clear breath sounds indicate that the lungs are not congested and there is no evidence of pulmonary pathology at this time. Therefore, this finding does not require follow-up.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is assessing a client who has a stage 3 pressure injury. Which of the following findings indicates possible infection of the wound?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who develops third-degree heart block with a heart rate of 30/min. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse in a provider's office is caring for a client. Exhibits Which of the following findings require follow-up? Select all that apply.

Correct Answer is ["A","B","D","F"]

Explanation

A nurse is assessing a client who had a total thyroidectomy 4 hr ago. Which of the following findings should the nurse report?

A nurse is reviewing a client's ECG rhythm strip. Which of the following components should the nurse use to measure impulse conduction from the sinus node through the atrioventricular node?

A nurse is caring for a client who has end-stage liver disease and is being placed on a transplant list. Which of the following statements by the client is the priority for the nurse to report to the provider?

A nurse is assessing a client who has disseminated intravascular coagulation. Which of the following findings should the nurse expect?

A nurse is assessing a client who reports numbness and tingling of their toes and exhibits a positive Trousseau's sign. Which of the following electrolyte imbalances should the nurse suspect?

The nurse is caring for the client who has iron deficiency anemia. Exhibits Which of the following instructions should the nurse include? Select all that apply.

A nurse is caring for a client who has experienced a stroke, decreased weight, and a decreased prealbumin. Which of the following interdisciplinary team members should the nurse anticipate collaborating with about the client's condition?

A nurse is preparing to administer 30 units of NPH and 10 units of regular insulin to a client. Which of the following actions should the nurse take?