Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.
Wound bed is red.
Redness noted at wound borders, skin surrounding wound is warm to touch
purulent drainage noted
Temp 38.9° C (102° F)
Hct 37% (37% to 47%)
WBC 13,500/mm3 (5000 to 10,000 mm3)
Wound bed is red.
Redness noted at wound borders, skin surrounding wound is warm to touch
purulent drainage noted
Temp 38.9° C (102° F)
WBC 13,500/mm3 (5000 to 10,000 mm3)
The Correct Answer is ["B","C","D","E"]
The findings that require follow-up:
- Redness noted at wound borders, skin surrounding wound is warm to touch
This suggests local infection or inflammation around the wound. - Purulent drainage noted
Purulent (thick, discolored) drainage is a sign of infection and requires prompt follow-up. - Temp 38.9° C (102° F)
This elevated temperature indicates a systemic response, likely due to infection. - WBC 13,500/mm³ (5000 to 10,000 mm³)
This is an elevated WBC count, consistent with infection or inflammation.
Incorrect answers:
- Wound bed is red
A red wound bed in a pressure injury is often a sign of granulation tissue, which is part of the normal healing process, not a concern unless accompanied by other signs of infection. - Hct 37% (37% to 47%)
Hematocrit is within normal limits, and does not indicate concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Use a cotton-tipped applicator to remove cerumen:
Inserting objects like cotton-tipped swabs into the ear canal is unsafe and can cause damage; not recommended for clearing earwax before temperature measurement.
B. Insert the probe snugly into the ear canal and press scan:
This is the correct method to ensure an accurate tympanic temperature reading.
C. Pull the pinna downward and backward:
This is correct for children under 3 years, not for adults.
D. Hold the probe flat against the forehead and press scan:
This technique is for a temporal artery thermometer, not tympanic.
Correct Answer is A
Explanation
A. A falsely high reading if the cuff is too small:
Using a cuff that is too narrow for the arm circumference can compress the artery more, resulting in a false high BP.
B. A falsely low reading if the cuff is wrapped too loosely around the arm:
This is true if a cuff is loose, but the question focuses on using a standard-size cuff, not an improperly applied one.
C. Accurate readings as long as it is 20% of the circumference of the midpoint of the limb:
The correct cuff width should be 40% of the limb’s circumference, and the bladder length should cover 80% of the arm.
D. Indistinct readings if the bladder encircles 80% of the adult's arm:
A bladder covering 80% of the arm is ideal and yields accurate readings.
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