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A nurse is caring for a client in a wound center.

Exhibits

Click to highlight the findings that indicate therapy has been ineffective. To deselect a finding, click on the finding again.

Nurses' Notes

Today:

Client presents for evaluation of wound vac therapy that was applied to surgical wound on their left knee 1 week ago.

Cilent rates pain as 8 on a scale of 0 to 10 in their left knee. Client reports no relief with pain medications.

Respirations even and nonlabored. Heart rate regular and fast. Abdomen soft and nondistended.

Left knee wound vac dressing removed. Left knee wound is 3 cm by 2 cm with 1 cm depth, Wound bed vascular with some approximation of the edges. Mild purulent drainage noted.

Cilent rates pain as 8 on a scale of 0 to 10 in their left knee

Client reports no relief with pain medications

Left knee wound is 3 cm by 2 cm with 1 cm depth

Wound bed vascular with some approximation of the edges

Mild purulent drainage noted

Answer and Explanation

The Correct Answer is ["A","B","C","E"]

Rationale:

Client rates pain as 8 on a scale of 0 to 10 in their left knee. Client reports no relief with pain medications. The client’s pain has worsened from 4/10 despite pain medication, indicating the current pain management approach is ineffective, and the wound may not be healing as expected.
Mild purulent drainage noted: The presence of purulent drainage is a sign of infection, further indicating that the wound vac therapy has not been successful in preventing or managing infection at the wound site.
Left knee wound is 3 cm by 2 cm with 1 cm depth, compared to 2 cm by 2 cm with 1 cm depth one week ago: The increase in wound sizefrom 2cm by 2 cm to 3 cm by 2 cm suggests that the wound vac therapy is not promoting healing effectively, leading to a failure of wound closure.

Rationale for Incorrect Choices:

Wound bed vascular with some approximation of the edges: The wound bed being vascular with some approximation of the edges indicates that there is some healthy tissue and the edges of the wound are coming together. This suggests that some healing is occurring, although it may be slower than expected.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["B","C","D","G"]

Explanation

A. Administer acetaminophen: Acetaminophen is useful for fever, but it does not improve respiratory status. The priority is to promote lung expansion and prevent complications like atelectasis, which is achieved through deep breathing, coughing, and ambulation.

B. Instruct the client to use the incentive spirometer five times per hour: Using the incentive spirometer frequently helps to expand the lungs and reduce the risk of atelectasis, a common postoperative complication. This intervention encourages deep breathing and improves oxygenation, which is essential for the client’s respiratory status.

C. Ambulate the client 30 min after administering analgesia: Ambulation promotes deep breathing and lung expansion, and it helps to mobilize secretions. Administering analgesia before ambulation ensures that the client is comfortable enough to participate in this activity.

D. Encourage the client to cough and breathe deeply: Encouraging deep breathing and coughing helps clear secretions from the lungs and promotes better oxygenation. This helps prevent respiratory complications especially after surgery when lung expansion is compromised.

E. Administer ondansetron: While ondansetron is necessary for controlling nausea, it does not directly improve the client’s respiratory status. However, if nausea is under control, the client may be more willing to participate in activities that promote lung expansion.

F. Administer supplemental oxygen: The current oxygen saturation of 92% is slightly low but not critical. The priority is to improve the client’s respiratory status through physical activity and breathing exercises before considering oxygen supplementation.

G. Encourage the client to splint the abdomen: Splinting the abdomen with a pillow while coughing or deep breathing reduces discomfort, especially after abdominal surgery. This technique helps the client engage in deep breathing and coughing more effectively.

A. "I'm sure your family will be here soon." B. "I will be available for you until your family arrives." C. "Why do you think your family is delayed?" D. "You'll feel better once this procedure is over."

Correct Answer is B

Explanation

A. "I'm sure your family will be here soon.": While this response tries to reassure the client, it does not address the client’s current feelings or provide immediate support. It might also come across as dismissive since the nurse cannot be sure when the family will arrive.

B. "I will be available for you until your family arrives.": This response acknowledges the client’s anxiety and offers support in the meantime. It shows the nurse’s availability and commitment to making the client feel safe and supported while waiting for their family.

C. "Why do you think your family is delayed?": This question might make the client feel pressured or defensive and focuses on the delay rather than offering reassurance or emotional support. It does not directly address the client’s emotional needs.

D. "You'll feel better once this procedure is over.": While this response aims to reassure the client, it might minimize their current feelings of anxiety. It focuses on the future rather than addressing the immediate emotional needs of the client.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client. Exhibits Which of the following actions should the nurse take to promote the client's respiratory status? Select all that apply.

Correct Answer is ["B","C","D","G"]

Explanation

A nurse in an urgent care center is caring for a young adult client who requires suturing of a laceration. The client tells the nurse, "My family should have been here by now. I can't go through this without them." Which of the following responses should the nurse make?

Correct Answer is B

Explanation

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