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

Explanation

Choice A reason: Stage 2 pressure injuries involve partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, and moist, and may also present as an intact or ruptured serum-filled blister. Since the wound involves subcutaneous tissue, it exceeds the criteria for Stage 2.

Choice B reason: Stage 1 pressure injuries are characterized by non-blanchable erythema of intact skin. While the skin is still intact, it may appear red and not lighten when pressed. Given the description of a wound involving subcutaneous tissue, Stage 1 is not appropriate.

Choice C reason: Stage 3 pressure injuries involve full-thickness loss of skin, where adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible, but the depth of tissue damage varies by anatomical location. This aligns with the wound involving subcutaneous tissue.

Choice D reason: Stage 4 pressure injuries involve full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone. While the wound described involves subcutaneous tissue, there is no mention of deeper tissue involvement, excluding Stage 4 classification.

A. Hypotension, chills, thirst B. Lethargy, confusion, bradycardia C. Bradycardia, hypotension, low urine output D. Fever, tachycardia, tremors

Correct Answer is D

Explanation

Choice A reason: Hypotension, chills, and thirst are not characteristic signs and symptoms of a thyroid storm. Hypotension generally indicates low blood pressure, while chills and thirst are less specific symptoms that do not particularly point to thyroid storm.

Choice B reason: Lethargy, confusion, and bradycardia are not typical indicators of a thyroid storm. These symptoms might be present in other conditions but are not generally associated with the severe hypermetabolic state seen in thyroid storms.

Choice C reason: Bradycardia, hypotension, and low urine output are also not typical signs of a thyroid storm. Bradycardia (slow heart rate) and hypotension (low blood pressure) are more likely associated with severe hypothyroidism or other conditions, not the hyperactive state of a thyroid storm.

Choice D reason: Fever, tachycardia, and tremors are classic signs of a thyroid storm. A thyroid storm is a life-threatening condition characterized by an excessive amount of thyroid hormones, leading to hypermetabolic activity. This results in symptoms like a high fever, rapid heart rate (tachycardia), and tremors.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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