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Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

Exhibits

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)

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Palpate the client’s pulse at the third intercostal space:
The apical pulse is at the fifth intercostal space, midclavicular line-not the third. The third is not standard for pulse assessment.

B. Ask the client to perform the Valsalva maneuver:
This can be used in arrhythmias like supraventricular tachycardia but is not appropriate for assessment of irregular rhythm.

C. Auscultate the client’s apical pulse:
This is the most accurate way to assess an irregular pulse, especially for one full minute.

D. Check the client’s heart rate for 30 sec:
When a rhythm is irregular, you must assess for a full minute, not 30 seconds.

A. Reposition the client every 3 hr. B. Provide the client with a diet high in protein. C. Apply cornstarch to keep the skin dry. D. Massage bony prominences to promote circulation.

Correct Answer is B

Explanation

A. Reposition the client every 3 hr:
At-risk clients should be repositioned at least every 2 hours, not every 3, to relieve pressure and promote circulation.

B. Provide the client with a diet high in protein:
Protein is essential for maintaining skin integrity and promoting tissue repair and healing.

C. Apply cornstarch to keep the skin dry:
Cornstarch can cause skin irritation and increase the risk of skin breakdown and infection in moist environments.

D. Massage bony prominences to promote circulation:
Massaging bony prominences can damage fragile tissues and increase the risk of pressure injuries.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an irregular heart rate. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the client's skin integrity?

Correct Answer is B

Explanation

A nurse palpates a client's radial pulses bilaterally and notes the client's right radial pulse is bounding, and the client's left radial pulse is as expected. The client's heart rate is 80/min. Which of the following documentations should the nurse make?

A nurse is collecting data about a client's circulatory system. Which of the following pulse sites should the nurse avoid checking bilaterally at the same time?

A nurse is collecting data on a client to check for orthostatic hypotension. Which of the following actions should the nurse take first?

A nurse is caring for a client whose surgical abdominal wound has eviscerated. Which of the following actions should the nurse take?

The young mother of an 8-month-old patient brought her daughter to the clinic after taking the little girl's temperature rectally and obtaining a reading of 100.4 F. The mother was concerned that her daughter might be ill. Which of the following is the best response?

A nurse is caring for a client who has a rectal temperature of 35° C (95° F). Which of the following actions should the nurse take?

A nurse is preparing to obtain a client's blood pressure. Which of the following actions should the nurse take to measure the blood pressure accurately?