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.

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Correct Answer is ["C","D"]

Explanation

Choice A reason: Placing the patient in restraints for safety is not typically necessary unless the patient is agitated or a danger to themselves or others. This action is not directly addressing the acute condition of a stroke.

Choice B reason: Inserting an NGT (nasogastric tube) is not an immediate priority in the acute management of a stroke. This might be considered later if the patient has swallowing difficulties and needs nutritional support, but it is not a first-line intervention.

Choice C reason: Anticipating thrombolytic therapy for ischemic stroke is appropriate, as timely administration of thrombolytics can dissolve the clot and improve blood flow to the affected brain area, potentially reducing the severity of the stroke.

Choice D reason: Establishing IV access with normal saline is crucial for administering medications and maintaining hydration. It ensures that the patient can receive necessary interventions promptly.

Choice E reason: Placing the patient in the prone position is not appropriate in the management of an acute stroke. The prone position is generally used in respiratory conditions to improve oxygenation but is not relevant to stroke management.

A. Keep the radiation area clean with mild soap and water B. Avoid exposing the radiation site to extreme temperatures C. Wear tight clothing to protect the skin D. Apply pleasant fragrant lotions to the radiation area

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

Explanation

Choice A reason: Keeping the radiation area clean with mild soap and water helps maintain hygiene and prevent infection. It is important to use gentle, non-irritating cleansers to avoid aggravating the skin that is already sensitive due to radiation.

Choice B reason: Avoiding exposure of the radiation site to extreme temperatures is crucial. Heat can increase irritation, and cold can cause additional discomfort. Protecting the area from extreme temperatures helps in reducing skin reactions and promoting healing.

Choice C reason: Wearing tight clothing is not recommended for patients undergoing radiation therapy. Tight clothing can cause friction and irritation on the already sensitive radiation site, potentially worsening skin reactions.

Choice D reason: Applying fragrant lotions to the radiation area is not advised. Fragrances and certain chemicals in lotions can irritate the skin and lead to adverse reactions. It is better to use unscented, gentle moisturizers if needed.

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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

Correct Answer is ["C","D"]

Explanation

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

Explanation

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