The nurse assesses a wound with exudate. What should be included when documenting the exudate? (Select all that apply.)

Color

Odor

Heat

Consistency

Amount

Answer and Explanation

Correct Answer : A,B,D,E

Choice A reason: Color is a characteristic of exudate that should be included when documenting it. Color can indicate the type and severity of the wound infection or inflammation. For example, yellow or green exudate may indicate a bacterial infection, while red or brown exudate may indicate bleeding or necrosis.

Choice B reason: Odor is a characteristic of exudate that should be included when documenting it. Odor can indicate the presence and type of microorganisms in the wound. For example, a foul or putrid odor may indicate anaerobic bacteria, while a sweet or fruity odor may indicate pseudomonas.

Choice C reason: Heat is not a characteristic of exudate that should be included when documenting it. Heat is a sign of inflammation that can be assessed by palpating the skin around the wound, not by observing the exudate. Heat does not directly reflect the quality or quantity of the exudate.

Choice D reason: Consistency is a characteristic of exudate that should be included when documenting it. Consistency can indicate the viscosity and composition of the exudate. For example, thin or watery exudate may indicate a serous or serosanguineous fluid, while thick or creamy exudate may indicate a purulent or fibrinous fluid.

Choice E reason: Amount is a characteristic of exudate that should be included when documenting it. Amount can indicate the extent and stage of the wound healing process. For example, a large amount of exudate may indicate a high level of inflammation or infection, while a small amount of exudate may indicate a low level of inflammation or infection.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: Calling the provider is not the intervention that the nurse should perform first, because it is not the most urgent and relevant action. Calling the provider is a communication intervention, not a respiratory intervention. Calling the provider is an important action, but it should be done after raising the head of the bed, and with accurate and complete information.

Choice B reason: Placing the client in the lithotomy position is not the intervention that the nurse should perform first, because it is not the most urgent and relevant action. Placing the client in the lithotomy position is a positioning intervention, not a respiratory intervention. Placing the client in the lithotomy position is a specific action that is used for pelvic examinations or procedures, not for improving oxygenation.

Choice C reason: Raising the head of the bed is the intervention that the nurse should perform first, because it is the most urgent and relevant action. Raising the head of the bed is a respiratory intervention, not a communication, positioning, or analgesic intervention. Raising the head of the bed is a simple and effective action that can improve the client's breathing, oxygenation, and comfort.

Choice D reason: Obtaining pain medication is not the intervention that the nurse should perform first, because it is not the most urgent and relevant action. Obtaining pain medication is an analgesic intervention, not a respiratory intervention. Obtaining pain medication is an important action, but it should be done after raising the head of the bed, and with a medical order and a proper route.

A. The client instills the prescribed number of eye drops into the conjunctival sac. B. The client washes her hands before instilling the eye drops. C. The client sets the cap to the eye drop container down in a manner that does not contaminate it. D. The client touches the administration dropper to the eye.

Correct Answer is D

Explanation

Choice A reason: The client instills the prescribed number of eye drops into the conjunctival sac is a correct action, because it ensures that the medication reaches the eye surface and does not spill out. The conjunctival sac is the space between the eyelid and the eyeball.

Choice B reason: The client washes her hands before instilling the eye drops is a correct action, because it prevents the introduction of microorganisms or foreign substances into the eye. Hand hygiene is an essential infection control measure.

Choice C reason: The client sets the cap to the eye drop container down in a manner that does not contaminate it is a correct action, because it preserves the sterility of the eye drop solution and prevents crosscontamination. The cap should be placed on a clean surface with the inner side facing up.

Choice D reason: The client touches the administration dropper to the eye is an incorrect action, because it can cause injury, infection, or contamination of the eye drop solution. The administration dropper should be held close to the eye, but not touch it.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse assesses a wound with exudate. What should be included when documenting the exudate? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's vital signs. The oxygen saturation is 85%. What intervention should the nurse perform first?

Correct Answer is C

Explanation

The nurse is providing education to a client regarding the administration of eye drops. Which of the following actions indicates the need for further client education?

Correct Answer is D

Explanation

Which of the following statements made by a client diagnosed with HIV demonstrates an understanding of the teaching?

The nurse is teaching a client with debilitating rheumatoid arthritis about home safety. Which statement should the nurse include?

What is an infectious disease that can be transmitted directly from one person to another?

A client is diagnosed with systemic lupus erythematosus (SLE). What symptom would the nurse expect to see?

An nurse is caring for a client who has acute osteomyelitis. Which of the following interventions is the nurse's priority?

Which assessment is a nonverbal sign of pain? (Select all that apply.)

What is a classic symptom assessed in clients with lupus?

A nurse is caring for a client who has methicillinresistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse prepares to enter the room to check the client's pulse. What personal protective equipment (PPE) should the nurse wear?