A nurse is caring for a client in a wound center.
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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Let me clarify that you want the medication given gid, correct?": When receiving a telephone prescription, it is essential to clarify any unclear aspects of the order, such as the dosage frequency. This ensures that the prescription is accurately understood and implemented and helps prevent medication errors.
B. "Will you please spell the name of that medication for me?": Although confirming the medication name is important, it is more critical to clarify the specific directions for administering the medication, such as the frequency, rather than spelling.
C. "I will sign my name now and leave a space for you to sign your name.": Offering to leave a space for the provider's signature is standard practice. However, it's not the most critical communication safety check during the verbal order itself.
D. "Let me provide you with the client's medical record number for identification.": While important for ensuring correct patient identification, the nurse should first focus on accurately obtaining the medication prescription and other critical details before providing identification information.
Correct Answer is A
Explanation
A. The client reports frequently having a headache in the morning: Frequent morning headaches can indicate sleep-related issues such as sleep apnea or bruxism (teeth grinding), both of which can significantly affect sleep quality and overall health.
B. The client reports having vivid dreams about their childhood: Vivid dreams can occur naturally, especially during rapid eye movement (REM) sleep. Although they may be unusual, they are not typically a cause for concern.
C. The client reports taking 30 min to fall asleep on average: Taking up to 30 minutes to fall asleep is within normal limits for most people. This is not a concerning finding and does not necessarily require reporting unless the client is experiencing other sleep disturbances.
D. The client reports sleeping about 7 hr on average: Sleeping around 7 hours per night is considered within the normal range for most adults. This is generally adequate sleep, and there is no indication of a significant issue that would require reporting to the provider.
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