The nurse assesses the wound of a client who received sutures for a laceration of the hand two days ago. Which finding is a normal inflammatory response?
Shivering.
Purulent drainage.
Temperature of 102° F (37.8° C).
Redness and localized heat.
The Correct Answer is D
A) Shivering:
Shivering is not a normal inflammatory response to wound healing. It may indicate systemic symptoms such as fever or chills, which could be indicative of infection or other complications.
B) Purulent drainage:
Purulent drainage (pus) is often a sign of infection rather than a normal inflammatory response to wound healing. While some serous or serosanguinous drainage may be expected initially, purulent drainage suggests an abnormal response.
C) Temperature of 102° F (37.8° C):
A temperature of 102° F (37.8° C) is indicative of fever, which can occur in response to infection or inflammation. While fever is part of the inflammatory response, it is not necessarily considered a normal finding in the context of wound healing and may indicate an abnormal response such as infection.
D) Redness and localized heat:
Correct. Redness (erythema) and localized heat are typical signs of the inflammatory phase of wound healing. Inflammation is a normal response to tissue injury and is characterized by increased blood flow to the area, resulting in redness and warmth. These signs indicate that the body's immune response is active and working to repair the injured tissue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Leukotrienes are inflammatory mediators derived from arachidonic acid metabolism, primarily produced by leukocytes (white blood cells) such as mast cells, eosinophils, and basophils. In the context of asthma, leukotrienes play a significant role in the pathophysiology of the disease by contributing to airway inflammation and bronchoconstriction. Here's a breakdown of their immune response:
A) Produce the sensation of itching:
Leukotrienes are not directly involved in producing the sensation of itching. Itching is often associated with histamine release rather than leukotrienes.
B) Tighten airway and produce mucous:
Correct. Leukotrienes are potent bronchoconstrictors that cause smooth muscle contraction in the airways, leading to narrowing (constriction) of the bronchioles. Additionally, they stimulate the secretion of mucus from goblet cells in the airway epithelium, contributing to airway obstruction and mucus production, which are characteristic features of asthma exacerbations.
C) Causes formation of bradykinin:
Bradykinin is a peptide mediator that is generated from the plasma protein kininogen and is involved in vasodilation, pain sensation, and inflammation. Leukotrienes are not directly responsible for the formation of bradykinin.
D) Serves as a receptor for antigen:
Leukotrienes do not serve as receptors for antigens. Instead, they are lipid mediators released in response to various stimuli, including allergens, infections, and irritants, and they act on specific receptors (e.g., leukotriene receptors) to exert their effects, such as bronchoconstriction and inflammation
Correct Answer is C
Explanation
DKA is a serious complication of diabetes mellitus characterized by hyperglycemia, ketosis, and metabolic acidosis. The laboratory results consistent with DKA include:
Elevated blood glucose level: A blood glucose level of 525 mg/dL (28 mmol/L) is significantly elevated and consistent with DKA.
Low arterial blood pH: A decreased arterial blood pH indicates acidosis, which is characteristic of DKA. Normal arterial blood pH ranges from 7.35 to 7.45.
Low bicarbonate (HCO3-) level: A low bicarbonate level indicates metabolic acidosis, which is also characteristic of DKA. Normal bicarbonate levels range from 21 to 28 mEq/L (21 to 28 mmol/L).
Among the options provided:
A) Arterial blood pH 7.5 and bicarbonate level 32 mEq/L (32 mmol/L):
This pH and bicarbonate level are indicative of alkalosis, which is not consistent with DKA.
B) Arterial blood pH 7.42 and bicarbonate level 18 mEq/L (18 mmol/L):
This pH is within the normal range, and the bicarbonate level is slightly decreased but not indicative of metabolic acidosis consistent with DKA.
C) Arterial blood pH 7.25 and bicarbonate level 10 mEq/L (10 mmol/L):
Correct. This pH is decreased, indicating acidosis, and the bicarbonate level is significantly below the normal range, consistent with metabolic acidosis characteristic of DKA.
D) Arterial blood pH 7.38 and bicarbonate level 29 mEq/L (29 mmol/L):
While the pH is within the normal range, the bicarbonate level is elevated, which is not consistent with metabolic acidosis seen in DKA.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.