A nurse is assessing a postoperative wound and notes purulent drainage. What should the nurse do first?
Document the findings and notify the healthcare provider.
Increase the frequency of dressing changes.
Clean the wound with sterile saline and apply a new dressing
Reassess the wound for additional signs of infection later in the shift.
The Correct Answer is A
A. Document the findings and notify the healthcare provider: Purulent drainage is a clear sign of infection and may indicate a need for prompt medical intervention, such as antibiotics. The nurse’s first action should be to notify the provider and document the findings to ensure timely, appropriate care.
B. Increase the frequency of dressing changes: While changing the dressing may help manage drainage, it does not address the underlying infection or the need for provider-directed treatment. Immediate notification is more critical.
C. Clean the wound with sterile saline and apply a new dressing: Maintaining wound hygiene is important, but it should follow assessment and provider notification. Acting first without notifying the provider may delay necessary treatment.
D. Reassess the wound for additional signs of infection later in the shift: Delaying assessment could allow the infection to worsen. Immediate documentation and communication with the provider are essential to prevent complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Introduce a blanket and stuffed animal to comfort the baby: Loose bedding and soft toys in the crib increase the risk of sudden infant death syndrome (SIDS) in newborns. This action is unsafe and not recommended for infants under 12 months.
B. Check for hunger, wet diaper, or cold and fix the issue quietly using minimal light and noise: Newborns wake frequently for basic needs. Addressing hunger, diaper changes, or temperature issues in a calm, quiet manner promotes restorative sleep and supports safety. Minimizing stimulation helps the baby return to sleep more easily.
C. Allow the baby to cry until they fall back asleep naturally: Letting a newborn “cry it out” is not appropriate at this age. Infants rely on caregivers for feeding, warmth, and comfort. Ignoring these needs can cause distress and disrupt healthy attachment.
D. Keep the baby awake during the day to reduce nighttime waking: Newborns have irregular sleep-wake cycles, and forcing wakefulness can lead to overtiredness, irritability, and difficulty feeding. Daytime sleep is essential for growth and development at this age.
Correct Answer is C
Explanation
A. Discussing the client's treatment plan in detail to ensure understanding: Providing information supports informed decision-making and adherence, but it reflects education rather than emotional attunement. This action focuses on cognitive understanding instead of acknowledging the client’s emotional experience. Empathy requires recognizing and validating feelings.
B. Reminding the client of their appointments to ensure compliance: Appointment reminders promote continuity of care and responsibility. However, this action emphasizes task completion rather than emotional connection. It does not convey understanding of the client’s internal emotional state.
C. Saying, “I understand that you're feeling overwhelmed, and I’m here to support you through this”: This response acknowledges the client’s emotional distress and conveys presence and support. It validates feelings without judgment or problem-solving. Such reflective communication is a core component of therapeutic empathy in mental health nursing.
D. Encouraging the client to attend group therapy sessions: Recommending group therapy may be clinically appropriate, but it shifts quickly into intervention. Without first acknowledging the client’s feelings, it lacks the emotional validation central to empathy. Empathy precedes guidance or referral.
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