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.

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Correct Answer is A

Explanation

A. Flush the PICC line with 0.9% sodium chloride after medication administration: This is essential to maintain patency and prevent occlusion as it helps clear any medication residue from the line and ensures proper blood flow.

B. Monitor for a pneumothorax following insertion of the PICC line: A pneumothorax is a potential complication following the insertion of a central venous catheter in the subclavian or internal jugular vein, not typically associated with PICC line insertion.

C. Use a 3 mL syringe when flushing the PICC line: A 10 mL or larger syringe is recommended. Using a 3 mL syringe could generate high pressure, causing damage to the PICC line or the vein, leading to complications such as catheter rupture or vein injury.

D. Expect the PICC line to be inserted into a lower extremity vein: PICC lines are typically inserted into veins in the upper extremities, such as the basilic or cephalic veins. Inserting a PICC line into a lower extremity vein can increase the risk of complications such as DVT.

A. "I had symptoms of asthma when I was a child." B. "My parent has type 2 diabetes mellitus.” C. "I am not very good about taking prescribed medication.” D. "I wish my family was more supportive of my decision."

Correct Answer is C

Explanation

A. "I had symptoms of asthma when I was a child.": Childhood asthma is not a significant concern in end-stage liver disease or transplant eligibility. It does not have a direct impact on the client’s current health status or the potential success of the liver transplant.

B. "My parent has type 2 diabetes mellitus.": While family medical history is relevant, having a parent with type 2 diabetes mellitus is not a contraindication for liver transplantation. The client’s own health status and adherence to medical care are more important.

C. "I am not very good about taking prescribed medication.": Post-transplant care requires strict adherence to medications, especially immunosuppressive drugs, to prevent organ rejection. If the client has a history of nonadherence, this can jeopardize the success of the transplant.

D. "I wish my family was more supportive of my decision.": This statement pertains to psychosocial concerns and can be addressed with counseling or support services. It does not pose an immediate medical concern for the transplant process.

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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

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