The nurse assesses two new wounds located on a client's right and left buttocks. Which intervention for wound management would the nurse employ? Select all that apply.

Palpate the client's skin for moisture, temperature, and texture.

Ask the client whether the wound bed or surrounding skin itches.

Measure and assess the client's wound bed, size, edges, and margins.

Evaluate the client's level of pain, using a numeric value pain scale.

Review the client's prothrombin time test and international normalized ratio.

Answer and Explanation

Correct Answer : A,C,D

Choice A rationale

Palpating the client's skin for moisture, temperature, and texture is essential in wound management. This allows the nurse to assess for signs of infection or inflammation, which can affect the wound healing process. Moisture can indicate excessive drainage or sweating that might macerate the skin, while changes in temperature and texture can signify infection or poor blood flow.

Choice B rationale

While asking the client whether the wound bed or surrounding skin itches may provide some information about the client's comfort, it is not a primary intervention for wound management. Itching can be a sign of healing or irritation, but it does not provide direct information on the wound's condition.

Choice C rationale

Measuring and assessing the wound bed, size, edges, and margins are critical steps in wound management. This helps to determine the progression of healing, the presence of necrotic tissue, and any changes in the wound over time. Accurate measurement and documentation are essential for developing an appropriate care plan.

Choice D rationale

Evaluating the client's level of pain using a numeric value pain scale is important in wound management. Pain can indicate underlying issues such as infection, poor perfusion, or neuropathy. Assessing pain helps guide interventions to provide comfort and address any complications that may arise.

Choice E rationale

Reviewing the client's prothrombin time test and international normalized ratio is not a standard intervention for wound management. These tests are more relevant to assessing the client's coagulation status, which may be important for surgical or anticoagulant therapy but not directly for wound care.

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Correct Answer is ["A","B","E"]

Explanation

Choice A rationale

Pinpoint pupils can indicate opioid use or damage to the pons, a part of the brainstem. This finding warrants further evaluation to determine the underlying cause and appropriate intervention.

Choice B rationale

Absence of pupillary response suggests severe brain injury or brainstem dysfunction. It is a critical finding that requires immediate medical attention to address potential life-threatening conditions.

Choice C rationale

Pupil reaction to light is a normal response indicating intact cranial nerve function. This finding does not raise neurologic concerns and does not require further investigation.

Choice D rationale

Quick pupil reaction is a normal response and indicates healthy cranial nerve function. This finding is not associated with neurologic concerns.

Choice E rationale

Unequal pupils, or anisocoria, can indicate increased intracranial pressure, brain injury, or nerve damage. This finding requires prompt assessment and intervention to prevent further complications.

A. Fast for at least 8 hours. B. Completion of the bowel cleansing regimen. C. Empty bladder. D. No allergy to penicillins.

Correct Answer is C

Explanation

Choice A rationale

Fasting for at least 8 hours is usually required for certain diagnostic tests that involve anesthesia or contrast media, but it is not necessary for a bone scan. A bone scan typically involves the injection of a radioactive tracer and does not require fasting.

Choice B rationale

Completion of a bowel cleansing regimen is necessary for certain gastrointestinal procedures such as colonoscopy, but it is not relevant for a bone scan. A bone scan focuses on detecting bone abnormalities and does not involve the digestive system.

Choice C rationale

Emptying the bladder is important before a bone scan to ensure clear imaging of the pelvic bones. A full bladder can obscure the view and interfere with the accuracy of the scan. Ensuring the bladder is empty helps in obtaining better diagnostic images.

Choice D rationale

No allergy to penicillins is crucial information for procedures involving antibiotics, especially for patients with a history of allergic reactions. However, it is not pertinent to a bone scan, which uses a radioactive tracer rather than antibiotics.

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The nurse assesses two new wounds located on a client's right and left buttocks. Which intervention for wound management would the nurse employ? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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