A nurse is assessing a patient with a surgical wound healing by secondary intention. Which finding should the nurse report to the charge nurse?

The wound is tender to touch.

The wound has a halo of erythema on the surrounding skin.

The wound is draining serosanguineous fluid.

The wound has pink, shiny tissue with a granular appearance.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Tenderness to touch is a common finding in wounds healing by secondary intention. It's often due to inflammation, which is a normal part of the healing process. The inflammation brings in cells and substances that promote healing. However, increased tenderness, especially when accompanied by other signs of infection, should be reported.

Choice B rationale:

A halo of erythema on the surrounding skin is a sign of infection. This is a serious complication that can delay healing and lead to further complications. The erythema indicates that the infection is spreading beyond the wound edges and needs prompt attention.

Choice C rationale:

Drainage of serosanguineous fluid is also common in wounds healing by secondary intention. This fluid is a mixture of serum (clear yellowish fluid) and blood. It's a sign that the wound is cleaning itself and new tissue is forming. While excessive drainage or a change in color or odor could signal a problem, drainage itself is not necessarily a cause for concern.

Choice D rationale:

Pink, shiny tissue with a granular appearance is a sign of healthy granulation tissue. This is a type of tissue that forms during the healing process. It's rich in blood vessels and collagen, which are essential for wound healing. The presence of granulation tissue indicates that the wound is healing well.

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Correct Answer is ["50"]

Explanation

Here are the steps to calculate the gtt/min for the manual IV infusion:

Step 1: Convert the infusion time from hours to minutes. 8 hours x 60 minutes/hour = 480 minutes

Step 2: Divide the total volume of fluid (in mL) by the infusion time in minutes to get the mL/min rate. 400 mL ÷ 480 minutes = 0.8333 mL/min

Step 3: Multiply the mL/min rate by the drop factor (gtt/mL) to get the gtt/min rate. 0.8333 mL/min x 60 gtt/mL = 50 gtt/min

Therefore, the nurse should set the manual IV infusion to deliver 50 gtt/min.

A. “Okay then; let me know if you need anything.” B. “That is not bad. C. “I understand you have had the pain for a while. Let’s investigate this further.” D. you know what might be causing the pain?” L. t me know if your pain becomes greater than 4 out of 10; then we can treat it.”

Correct Answer is C

Explanation

Choice A rationale:

This response is dismissive of the patient's pain and does not offer any assistance. It also does not acknowledge the patient's concerns about their pain being a normal part of aging.

It's important to validate the patient's experience and offer support, even if the pain level is not severe.

This response could lead to the patient feeling unheard and unsupported, and it could potentially delay necessary treatment.

Choice B rationale:

This response suggests that the patient's pain is not significant enough to warrant treatment unless it worsens. This is not appropriate, as pain is subjective and should be treated based on the patient's individual experience.

Additionally, this response reinforces the patient's belief that pain is a normal part of aging, which may prevent them from seeking treatment in the future.

Choice C rationale:

This response is the best option because it acknowledges the patient's pain, expresses concern, and suggests further investigation.

It is important to rule out any underlying medical conditions that may be causing the pain.

This response also demonstrates to the patient that the nurse is taking their pain seriously and is committed to helping them manage it.

Choice D rationale:

This response acknowledges that pain can be a part of aging, but it also suggests that there may be a specific cause for the patient's pain.

This could lead to the patient feeling anxious or worried about their health.

It is important to investigate the cause of the pain before making any assumptions.

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A nurse is assessing a patient with a surgical wound healing by secondary intention. Which finding should the nurse report to the charge nurse?

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer 400 mL of 0.9% sodium chloride IV over 8 hours. The drop factor of the manual IV tubing is 60 gtt/mL. How many gtt/min should the nurse set the manual IV infusion to deliver? (Input your answer into the blank space, without any units. Numerical value only.)

Correct Answer is ["50"]

Explanation

A 79-year-old patient reports a pain level of 3 out of 10 and states, “Don’t worry, this is just part of getting old.” What is the best response?

Correct Answer is C

Explanation

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