The nurse is caring for a patient who has had a pressure injury. When assessing the wound, which finding causes the greatest concern for the nurse?

Amber fluid

Clear drainage

Purulent, draining wound

Blood-tinged fluid

Answer and Explanation

The Correct Answer is C

Choice A reason: Amber fluid is typically a sign of serous exudate, which is a normal part of the inflammatory process and wound healing. It indicates the body's immune response to the injury and is generally not a cause for concern unless the volume significantly increases or changes in appearance.

Choice B reason: Clear drainage, or serous fluid, is also a normal finding in wound healing. It indicates that the wound is exuding plasma, which helps to keep the wound moist and supports the healing process. This type of drainage is typically not worrisome unless there are other signs of infection or complications.

Choice C reason: Purulent, draining wound is a major concern as it indicates the presence of pus, which is often a sign of infection. Purulent drainage can be yellow, green, or brown and is usually thick and malodorous. The presence of pus suggests that there are bacteria or other pathogens in the wound, and immediate medical intervention is necessary to prevent further complications and promote healing.

Choice D reason: Blood-tinged fluid, or serosanguinous drainage, is common in fresh wounds or after debridement. It indicates a mixture of plasma and red blood cells and can be seen in the early stages of wound healing. While it is generally not alarming, the nurse should monitor the volume and changes in the drainage to ensure there are no signs of excessive bleeding or infection.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

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

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: Eating foods high in potassium can be important for patients taking diuretics, as diuretics can cause potassium loss. However, for SIADH patients, this is not a primary focus unless they are on diuretics that specifically lead to potassium loss.

Choice B reason: Limiting fluid intake is crucial for patients with SIADH to prevent fluid overload and hyponatremia. This statement aligns with proper management of the condition.

Choice C reason: Patients with SIADH need to carefully manage their sodium intake. Rather than reducing sodium, they often need to maintain or increase their sodium intake to help counteract the effects of SIADH, which causes dilutional hyponatremia (low blood sodium levels). Therefore, this statement indicates a need for additional instruction.

Choice D reason: Weighing oneself daily is an important practice for SIADH patients to monitor for sudden weight changes, which can indicate fluid imbalances. This statement is appropriate and does not require additional instruction.

A. Weight gain B. Cardiovascular problems C. Swallowing challenges D. Obesity

Correct Answer is C

Explanation

Choice A reason: Weight gain is not commonly associated with Parkinson's disease. In fact, patients with PD often experience weight loss due to increased energy expenditure from tremors and muscle rigidity, as well as difficulties with eating.

Choice B reason: Cardiovascular problems are not directly caused by Parkinson's disease. While PD patients may have cardiovascular issues, these are typically related to age or other comorbid conditions rather than PD itself.

Choice C reason: Swallowing challenges, or dysphagia, are a significant concern for patients with Parkinson's disease. The motor symptoms of PD, including muscle rigidity and bradykinesia, can affect the muscles involved in swallowing, leading to difficulty eating and an increased risk of aspiration and choking. Addressing swallowing challenges is crucial for maintaining nutrition and preventing respiratory complications.

Choice D reason: Obesity is not a typical issue for patients with Parkinson's disease. As mentioned earlier, weight loss is more common due to the disease's impact on motor function and the effort required for daily activities.

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 is caring for a patient who has had a pressure injury. When assessing the wound, which finding causes the greatest concern for the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which patient statement indicates to the nurse that additional instruction is needed for a patient with chronic syndrome of inappropriate antidiuretic hormone (SIADH)?

Correct Answer is C

Explanation

Which clinical problem would the nurse include in the care plan for a patient with Parkinson's disease (PD)?

Correct Answer is C

Explanation

The nurse works in a clinic located in a community where many of the residents are Hispanic. Which strategy, if implemented by the nurse, would decrease health care disparities and promote health equity for this community?

When a patient with asthma who is on a budesonide hand-held inhaler reports difficulty, what should the nurse do?

Which information is most important for the nurse to include when teaching a patient newly diagnosed with hypertension?

A patient is being discharged home for treatment of hypothyroidism. Which medication is most commonly prescribed for this condition?

The nurse provides postoperative care to a patient who underwent peripheral artery bypass surgery. Thirty minutes after the initial assessment, the nurse reassesses the patient and detects a change in the Doppler sound over a pulse. Which action should the nurse take?

Identify two causes of ascites related to liver cirrhosis:

Choose appropriate interventions to stabilize the patient with acute anemia. Select all that apply.