Precise wound documentation contributes to which of the below elements? (Select all that apply)

Continuity of Care

Accurate Evaluation of Care

Appropriate changes in wound

Closed drainage system

Answer and Explanation

Correct Answer : A,B,C

Choice A reason: Precise wound documentation ensures continuity of care by providing a detailed record of wound characteristics, treatments, and progress. This allows multiple providers to deliver consistent care, reducing errors and ensuring interventions align with the patient’s healing trajectory, per interdisciplinary care and documentation standards.

Choice B reason: Accurate evaluation of care relies on precise wound documentation, which tracks changes in size, depth, and healing status. This enables providers to assess treatment effectiveness, adjust plans, and prevent complications, ensuring evidence-based care delivery, per wound management and clinical evaluation protocols.

Choice C reason: Appropriate changes in wound care are guided by precise documentation, which identifies healing trends or deterioration. Detailed records inform timely modifications to dressings or therapies, optimizing outcomes and preventing infection or delayed healing, per wound care decision-making and clinical practice guidelines.

Choice D reason: A closed drainage system relates to wound management devices, not documentation. While documentation may note drainage system use, it does not directly contribute to its function. Precise documentation supports care planning, not mechanical systems, making this irrelevant to the question, per wound care technology.

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Correct Answer is B

Explanation

Choice A reason: Bradycardia (pulse <60 bpm) is unlikely, as fever, infection, and pain increase sympathetic nervous system activity, elevating heart rate. Infection triggers cytokine release, and pain stimulates adrenaline, both increasing cardiac output to meet metabolic demands. Bradycardia would contradict the physiological stress response, making this incorrect for this scenario.

Choice B reason: Tachycardia (pulse >100 bpm) is likely due to fever, infection, and pain activating the sympathetic nervous system. Fever increases metabolic rate, infection induces inflammatory cytokines, and pain releases adrenaline, all elevating heart rate to enhance oxygen delivery. This physiological response matches the client’s condition, making tachycardia the correct pulse type.

Choice C reason: Dysrhythmia involves irregular heart rhythms, like atrial fibrillation, not directly caused by fever, infection, or pain. These conditions increase heart rate via sympathetic stimulation, not necessarily rhythm irregularity. Dysrhythmias require specific cardiac issues, unlike the expected tachycardia from systemic stress, making this incorrect for the client’s presentation.

Choice D reason: Bigeminal pulse (paired beats) indicates a specific arrhythmia, not typically caused by fever, infection, or pain. These conditions elevate heart rate through sympathetic activation and cytokine release, leading to tachycardia, not patterned beats. Bigeminal rhythms require cardiac-specific issues, making this an unlikely pulse type in this systemic stress scenario.

A. Dysrhythmia B. Tachycardia C. Bradycardia D. Normal pulse

Correct Answer is B

Explanation

Choice A reason: Dysrhythmia refers to an irregular rhythm, not a specific rate. An apical pulse of 140 indicates a fast rate, not necessarily irregular, so tachycardia is more accurate. Dysrhythmia requires evidence of irregularity, not present here, per cardiac assessment terminology.

Choice B reason: Tachycardia is an apical pulse above 100 bpm, and 140 fits this definition, indicating a rapid heart rate. This requires further investigation for causes like pain or hypoxia, ensuring accurate documentation and intervention, per cardiovascular assessment and clinical terminology standards.

Choice C reason: Bradycardia is a pulse below 60 bpm, not applicable to 140. This rapid rate indicates tachycardia, not a slow heart, requiring different management. Mislabeling as bradycardia could lead to inappropriate care, per cardiac physiology and documentation guidelines.

Choice D reason: A normal pulse is 60-100 bpm, not 140. This rate indicates tachycardia, a pathological finding needing evaluation. Documenting as normal ignores a significant abnormality, risking delayed intervention, per clinical standards for pulse rate assessment and documentation.

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Precise wound documentation contributes to which of the below elements? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a fever, has an infection of a flank incision, and is in severe pain. What type of pulse rate would the client most likely exhibit?

Correct Answer is B

Explanation

An adult client is assessed as having an apical pulse of 140. How would the nurse document this finding?

Correct Answer is B

Explanation

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