A nurse is caring for a client with a wound. Which of the following pairings reflect the correct wound infection stage with description?
Colonization - replicating microorganisms: not yet Infected
Systemic infection - Wound is darker than the surrounding skin with noted drainage present
Contaminated - infection beyond the wound
Local infection - sepsis
The Correct Answer is A
A. Colonization - replicating microorganisms: not yet Infected
This pairing is correct. Colonization refers to the presence and replication of microorganisms on the wound surface. At this stage, the wound is not yet infected, as there may be microorganisms present, but they have not caused an inflammatory response or tissue damage.
B. Systemic infection - Wound is darker than the surrounding skin with noted drainage present
This description does not match the stage of systemic infection. Systemic infection refers to an infection that has spread beyond the initial wound site, affecting the entire body systemically. The symptoms of systemic infection may include fever, increased heart rate, malaise, and altered mental status. The description provided seems more indicative of a local infection with drainage.
C. Contaminated - infection beyond the wound
This pairing is incorrect. Contaminated wounds refer to wounds with a high risk of infection due to the presence of foreign material or significant contamination. However, contamination does not necessarily mean that an infection has already developed beyond the wound. It signifies a risk of infection but does not define the infection stage itself.
D. Local infection - sepsis
This pairing is incorrect. A local infection is confined to the wound site and may present with symptoms such as erythema, warmth, swelling, pain, and purulent drainage. Sepsis, on the other hand, is a severe systemic response to infection, characterized by widespread inflammation and organ dysfunction. Sepsis is not synonymous with a local infection; it represents a more advanced and life-threatening stage of infection.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Prevents complications, such as meningitis or pneumonitis
While oral acyclovir can be effective in managing HSV infections and reducing the severity of symptoms, it is not primarily used to prevent complications such as meningitis or pneumonitis. These complications may occur in severe cases of HSV infections, but oral acyclovir's main goal is to manage outbreaks and reduce symptoms.
B. Decreases the probability of recurrent outbreaks
Oral acyclovir can help reduce the frequency of recurrent outbreaks in individuals with HSV infections. However, it does not completely eliminate the probability of recurrent outbreaks. Some individuals may still experience occasional outbreaks even with regular use of oral acyclovir. The medication is more focused on managing outbreaks when they occur rather than preventing them entirely.
C. Shortens the outbreak and lessens the severity of symptoms
This option is the correct choice. Oral acyclovir is effective in shortening the duration of HSV outbreaks and reducing the severity of symptoms such as pain, itching, and lesions. It works by inhibiting the replication of the virus, which helps in faster healing and symptom relief. However, it does not cure the infection or eliminate the virus from the body.
D. Eliminates the likelihood of spreading the infection to others
While oral acyclovir can help manage outbreaks and reduce viral shedding, it does not completely eliminate the risk of spreading the infection to others. It can reduce the likelihood of transmission during active outbreaks, but individuals with HSV can still shed the virus and be contagious even when they are not experiencing visible symptoms. Therefore, other precautions such as practicing safe sex and avoiding close contact during outbreaks are also important for preventing transmission.
Correct Answer is A
Explanation
A. Keeping the wound clean and non-infected: When caring for a client with a pressure injury, the priority in the plan of care is to keep the wound clean and prevent infection. This involves regular wound assessment, proper wound cleaning techniques, application of appropriate dressings, and monitoring for signs of infection such as increased redness, swelling, warmth, or drainage. Preventing infection is crucial for promoting healing and preventing complications.
B. Application of a negative pressure wound care device: While negative pressure wound therapy (NPWT) can be beneficial in promoting wound healing, it may not be the immediate priority unless specifically indicated by the healthcare provider based on the stage and characteristics of the pressure injury. Keeping the wound clean and preventing infection take precedence over NPWT in the initial plan of care.
C. Client education on wound prevention: While client education is important for preventing future pressure injuries, it is not the immediate priority when caring for an existing pressure injury. The focus initially should be on managing the current wound to promote healing and prevent complications.
D. Promoting a high carbohydrate, low protein diet: Nutritional interventions are important in wound healing, but promoting a specific diet is not the immediate priority in the plan of care for a pressure injury. Providing adequate nutrition and addressing any nutritional deficiencies may be part of the overall plan, but it is secondary to keeping the wound clean and preventing infection.
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