During an assessment, a nurse notes purulent drainage from a patient's open wound. What does this finding suggest?
Normal healing process.
Eschar formation.
Presence of infection.
Granulation tissue.
The Correct Answer is C
A. Normal healing process: Normal healing involves serous or serosanguineous drainage. Purulent drainage signifies a complication (infection).
B. Eschar formation: Eschar is hard, black, necrotic tissue; it is not a type of drainage.
C. Presence of infection: Purulent drainage (pus)-which is thick, opaque, and often yellow, green, or brown-is composed of dead white blood cells, bacteria, and tissue debris, indicating a localized bacterial infection.
D. Granulation tissue: Granulation tissue is bright red, moist, and bumpy tissue, which is a sign of the proliferative phase of normal healing, not the fluid component.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Increase the frequency of wound dressing changes:This is an appropriate measure to manage exudate and clean the wound, but it is not the highest priority action for treating the underlying infection.
B. Initiate contact isolation precautions:This is necessary if the organism requires isolation (e.g., MRSA), but it is a safety measure, not the clinical priority for treating the patient's infection.
C. Apply a non-adherent dressing:This is an appropriate dressing choice for a healing wound, but the priority is treating the infection itself.
D. Administer prescribed antibiotics:An infected Stage 3 pressure ulcer (confirmed or highly suspected) requires systemic treatment. Administering the prescribed antibiotic is the most critical intervention to prevent the localized infection from escalating to a systemic infection (sepsis) and to eliminate the bacteria that are stalling the healing process.
Correct Answer is B
Explanation
A. Massage the reddened area to improve circulation:Massaging a reddened area (likely a Stage 1 pressure injury) can cause further damage to the underlying blood vessels and increase the risk of deeper tissue injury.
B. Apply a moisture barrier cream to the sacral area: This is a crucial intervention, especially if the client is incontinent, as it protects the skin from chemical irritation and maceration. However, it does not address the primary cause: unrelieved pressure.
C. Reposition the client every 4 hours: For a bedridden client with signs of breakdown, the standard of care requires repositioning at least every 2 hours (and often more frequently) to significantly reduce the risk of tissue ischemia caused by prolonged pressure. Repositioning every 4 hours is inadequate.
D. Elevate the head of the bed to 45°: The head of the bed should be kept at or below 30° (unless medically contraindicated) to minimize the effects of shear and friction on the skin of the sacrum and coccyx. Elevating to 45° increases shear and pressure risk.
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