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

Exhibits

Click to highlight the documentation in the client's medical record that requires further action by the nurse. To deselect information, click on the information again.

Day 4:

Hydrocolloid dressing removed. Client has a 2.5 cm (1 in) x 3 cm (1.2 in) stage 3 pressure injury on left heal. Increased redness at wound borders and purulent drainage noted.

Temperature 38.9° C (102° F)

BP 118/56 mm Hg

Heart rate 102/min

Respiratory rate 22/min

Pulse oximetry 95% on room air

Hct 38% (37% to 47%)

Hgb 12 g/dl (12 g/dL to 16 g/dL)

WBC 12,000/mm (5,000 to 10,000 mm)

Client has a 2.5 cm (1 in) x 3 cm (1.2 in) stage 3 pressure injury on left heal

Increased redness at wound borders and purulent drainage noted

Temperature 38.9° C (102° F)

BP 118/56 mm Hg

Pulse oximetry 95% on room air

Hct 38% (37% to 47%)

Hgb 12 g/dl (12 g/dL to 16 g/dL)

WBC 12,000/mm (5,000 to 10,000 mm)

Answer and Explanation

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

Rationale for Correct Answers:

Client has a 2.5 cm (1 in) x 3 cm (1.2 in) stage 3 pressure injury on left heel: The wound has increased in size from 2.0 cm to 2.5 cm, indicating worsening tissue damage. Progression in wound size suggests ineffective treatment and warrants reassessment of the care plan.
Increased redness at wound borders: New or worsening erythema around the wound border is a sign of local infection or inflammation. This finding suggests that the wound environment may be contaminated or inflamed.
Purulent drainage noted: The presence of thick, colored exudate indicates bacterial infection at the wound site. This type of drainage typically requires culture, new dressing orders, and possibly antibiotics.
Temperature 38.9°C (102°F): This elevated temperature indicates a febrile response, often associated with systemic infection. The fever, along with local wound signs, may point to cellulitis or sepsis risk.
WBC 12,000/mm³: A white blood cell count above the normal range reflects systemic inflammation or infection. When coupled with fever and purulence, this reinforces the need for urgent evaluation and treatment.

Rationale for Incorrect Choices:

BP 118/56 mm Hg: This minimal change in blood pressure from 128 to 118, is not a primary indicator of a problem requiring immediate "further action" in the context of the other, more striking findings.
Pulse oximetry 95% on room air: This oxygen level is within the normal range and indicates adequate gas exchange. It does not point to respiratory distress or infection-related hypoxia.
Hgb 12 g/dL and Hct 38%: Both values are within the reference range for women and do not indicate anemia or bleeding. They are not relevant to infection progression or pressure injury management.

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"C"},"E":{"answers":"A"},"F":{"answers":"B"}}

Explanation

Potential Order	Anticipated	Nonessential	Contraindicated
Ambulate in hallway with supervision		✓
Ketorolac IV for pain	✓
Ice packs to affected area 15 min or 5 min off			✓
Meperidine for pain			✓
Intravenous fluids (IVF) at maintenance rate	✓
Oxygen in 2L/min via nasal cannula		✓

Ambulate in hallway with supervision: While mobility helps prevent complications, it is not a priority during an acute pain crisis. The client is in severe pain and resisting movement, so ambulation would be inappropriate until pain is better controlled.
Ketorolac IV for pain: Ketorolac, a nonsteroidal anti-inflammatory drug (NSAID), is commonly used adjunctively in sickle cell crises for its analgesic and anti-inflammatory effects, especially when opioids alone are ineffective.
Ice packs to affected area: Cold therapy causes vasoconstriction, which can worsen sickling and ischemia in clients with sickle cell disease. Heat therapy is preferred for promoting circulation during a vaso-occlusive episode.
Meperidine for pain: Meperidine is avoided in sickle cell disease due to the risk of neurotoxicity (e.g., seizures) from its metabolite, normeperidine, especially with repeated doses or in renal impairment.
Intravenous fluids (IVF) at maintenance rate: Hydration is critical in sickle cell crises to reduce blood viscosity and prevent further sickling. IV fluids are a standard component of treatment during acute pain episodes.
Oxygen 2 L/min via nasal cannula: The client is not hypoxic and has a normal respiratory rate (18 / min), and routine oxygen is not required unless oxygen saturation decreases. Overuse of oxygen can suppress erythropoiesis in chronic use.

A. +1 posterior tibial pulse B. Hair loss C. History of hypertension D. Pale wound bed E. Pain at ulcer site F. Defined edges G. Skin cool to touch of the affected extremity

Correct Answer is {"A":{"answers":"A,C"},"B":{"answers":"A,C"},"C":{"answers":"A,B,C"},"D":{"answers":"A,C"},"E":{"answers":"A,C"},"F":{"answers":"A,C"},"G":{"answers":"A,C"}}

Explanation

Assessment Findings	Arterial ulcer	Venous ulcer	Diabetic ulcer
+1 posterior tibial pulse	✓		✓
Hair loss	✓		✓
History of hypertension	✓	✓	✓
Pale wound bed	✓		✓
Pain at ulcer site	✓		✓
Defined edges	✓		✓
Skin cool to touch of the affected extremity	✓		✓

+1 posterior tibial pulse: A diminished pulse supports arterial insufficiency and is frequently seen in both arterial and diabetic ulcers due to vascular complications in diabetes. Venous ulcers usually have normal pulses unless complicated by edema.
Hair loss: Loss of hair on the lower extremities is a classic sign of arterial insufficiency, but it is also common in diabetic neuropathy where circulation is impaired. Venous ulcers rarely show this sign.
History of hypertension: Hypertension is a risk factor for arterial disease, venous insufficiency (due to increased venous pressure), and diabetes-related vascular complications, making it relevant to all three ulcer types.
Pale wound bed: Pallor in the wound bed suggests poor oxygenation and perfusion, which is characteristic of arterial ulcers. Diabetic ulcers may also have poor granulation due to impaired healing. Venous ulcers are more often red and moist.
Pain at ulcer site: Pain with walking that improves with rest suggests intermittent claudication and ischemia, consistent with arterial ulcers. Diabetic ulcers can also be painful, especially if infection or inflammation is present. Venous ulcers tend to cause more aching or heaviness rather than sharp pain.
Defined edges: Ulcers with sharply demarcated, punched-out edges are typical of arterial and diabetic ulcers. Venous ulcers usually have irregular, shallow borders.
Skin cool to touch of the affected extremity: Cool skin reflects decreased blood flow and is characteristic of arterial ulcers. It is also common in diabetic ulcers due to associated peripheral artery disease. Venous ulcers tend to have warm, swollen limbs due to fluid accumulation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an adolescent. Exhibits For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"C"},"E":{"answers":"A"},"F":{"answers":"B"}}

Explanation

A nurse is caring for a client. Exhibits For each assessment finding, click to specify if the assessment finding is consistent with an arterial ulcer, a venous ulcer, or a diabetic ulcer. Each finding may support more than one disease process.

Correct Answer is {"A":{"answers":"A,C"},"B":{"answers":"A,C"},"C":{"answers":"A,B,C"},"D":{"answers":"A,C"},"E":{"answers":"A,C"},"F":{"answers":"A,C"},"G":{"answers":"A,C"}}

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