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A nurse is caring for a client who has a pressure injury.

Click to highlight the findings that the nurse should report to the provider. To deselect a finding, click on the finding again.

Temperature

WBC count

Prealbumin level

Hemoglobin level

Blood pressure

Pain level

Odor of wound

Bowel sounds

Answer and Explanation

Correct Answer : A,B,C,F,G

A. Temperature: A temperature of 38.3°C (101°F) indicates fever, which can signal a systemic inflammatory response or infection. In a client with a pressure injury that has developed purulent drainage and foul odor, fever raises concern for wound infection or possible systemic spread. This finding requires prompt provider notification for potential antibiotic therapy and further evaluation.

B. WBC count: A WBC count of 12,000/mm³ is elevated above the normal range and suggests an inflammatory or infectious process. In the context of a worsening pressure injury with purulent drainage, leukocytosis supports the possibility of an active infection. Reporting this finding allows the provider to consider diagnostic tests and treatment such as wound cultures or antimicrobial therapy.

C. Prealbumin level: The prealbumin level of 12 mg/dL is below the normal range, indicating poor nutritional status. Adequate protein and caloric intake are essential for wound healing and tissue regeneration. Low prealbumin can impair the healing of pressure injuries and may require nutritional intervention, supplementation, or referral to a dietitian.

D. Hemoglobin level: The hemoglobin level of 13 g/dL falls within the normal reference range for adults. Adequate hemoglobin supports oxygen delivery to tissues, which is important for wound healing. Because this value is within normal limits, it does not require reporting as an abnormal finding.

E. Blood pressure: The blood pressure reading of 128/64 mm Hg is within an acceptable range and does not indicate hemodynamic instability. There are no signs of hypotension or hypertension that would compromise tissue perfusion or indicate acute deterioration. Therefore, this value does not require immediate reporting.

F. Pain level: The client’s pain has increased from 2/10 on Day 1 to 6/10 on Day 4, indicating worsening discomfort. Increasing pain in a pressure injury may signal infection, tissue deterioration, or inflammation. This change in pain level should be reported because it represents a significant clinical change requiring reassessment of wound management and pain control.

G. Odor of wound: A foul odor from a pressure injury is commonly associated with bacterial infection or necrotic tissue. When combined with purulent drainage and yellow wound tissue, it strongly suggests wound deterioration and possible infection. This finding should be reported promptly for evaluation and potential treatment adjustments.

H. Bowel sounds: Active bowel sounds in all four quadrants indicate normal gastrointestinal motility. This is a normal assessment finding and is unrelated to the client’s pressure injury status. Because it does not represent a complication or abnormal change, it does not need to be reported to the provider.

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Correct Answer is B

Explanation

A. Ask the client to consider a direct donation: Direct donation involves receiving blood donated by a specific individual, often a relative or friend. Although this option may sometimes be offered for transfusion preferences, it does not address the client’s refusal based on religious beliefs. Suggesting this does not respect the client’s expressed decision.

B. Withhold the blood transfusion: A competent adult has the legal and ethical right to refuse medical treatment, including life-saving interventions such as blood transfusions. Respecting the principle of autonomy requires honoring the client’s informed refusal once they demonstrate decision-making capacity and understanding of the consequences.

C. Request a consultation with the ethics committee: Ethics consultations are helpful when there is uncertainty about the ethical course of action or conflict regarding decision-making capacity. In this situation, the client has clearly refused treatment for religious reasons, which is a legally protected right. Patient autonomy is already clear, so consultation is not the immediate priority.

D. Ask the client's family to intervene: Family members may express strong opinions about treatment decisions, but they do not have authority to override the decision of a competent adult client. Encouraging the family to intervene could place pressure on the client and undermine their autonomy. The nurse’s role is to support the client’s informed choice.

A. Place the client on droplet isolation precautions. B. Apply oxygen at 2 L/min via nasal cannula. C. Request a prescription for an antipyretic medication. D. Wear an N95 mask when providing care to the client. E. Request a prescription for an antihypertensive medication. F. Remain 1 m (3 feet) from the client.

Correct Answer is ["A","B","C","F"]

Explanation

A. Place the client on droplet isolation precautions: Bacterial pneumonia is commonly transmitted through respiratory droplets generated by coughing, sneezing, or talking. Droplet precautions reduce the risk of transmission to healthcare workers and other patients. Initiating or maintaining droplet isolation is appropriate in an infectious respiratory disease.

B. Apply oxygen at 2 L/min via nasal cannula: The client’s oxygen saturation is 91% on room air, which indicates mild hypoxemia and inadequate oxygenation. Supplemental oxygen via nasal cannula helps increase the fraction of inspired oxygen and improve arterial oxygen saturation. Providing low-flow oxygen is an appropriate initial intervention.

C. Request a prescription for an antipyretic medication: The client’s temperature is 38.6°C (101.5°F), indicating fever associated with infection and systemic inflammatory response. Antipyretic medications such as acetaminophen can help reduce fever, decrease metabolic demand, and improve comfort. Managing fever is an important supportive intervention.

D. Wear an N95 mask when providing care to the client: N95 respirators are required for airborne precautions, which are used for diseases transmitted through very small aerosolized particles such as tuberculosis or measles. Pneumonia is typically managed with droplet precautions, which require a surgical mask rather than an N95 respirator.

E. Request a prescription for an antihypertensive medication: The client’s blood pressure is 110/68 mm Hg, which is within a normal range and does not indicate hypertension. Administering or requesting antihypertensive therapy in this situation would be inappropriate and could potentially lower blood pressure unnecessarily.

F. Remain 1 m (3 feet) from the client:Large respiratory droplets generally do not travel further than 3 to 6 feet. Maintaining a distance of at least 1 meter (3 feet) is a standard component of droplet precautions when not providing direct care.

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A nurse is caring for a client who has a pressure injury. Click to highlight the findings that the nurse should report to the provider. To deselect a finding, click on the finding again.

Nursing Test Bank

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Correct Answer is B

Explanation

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Correct Answer is ["A","B","C","F"]

Explanation

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A nurse is caring for a client who has a pressure injury.

Click to highlight the findings that the nurse should report to the provider. To deselect a finding, click on the finding again.