The nurse is changing a client’s abdominal surgical dressing. Which finding warrants notification to the healthcare provider?

Yellow purulent drainage.

Pink granulation tissue.

Serosanguineous fluid.

Approximated wound edges.

Answer and Explanation

The Correct Answer is A

Choice A reason: Yellow purulent drainage indicates wound infection, likely from bacterial proliferation (e.g., Staphylococcus aureus) causing pus. This serious complication risks delayed healing, abscess, or sepsis, necessitating provider notification for cultures, antibiotics, or surgical intervention. Infection disrupts tissue repair, requiring urgent management to prevent systemic spread or wound dehiscence.

Choice B reason: Pink granulation tissue is normal in wound healing, reflecting angiogenesis and fibroblast activity during the proliferative phase. It indicates healthy tissue formation, not requiring notification. Purulent drainage, however, signals infection, a critical issue disrupting healing and risking complications, making it the priority finding for reporting.

Choice C reason: Serosanguineous fluid, a mix of serum and blood, is expected in early surgical wounds as capillaries heal. It does not indicate infection unless excessive. Purulent drainage is more urgent, directly suggesting bacterial infection, which can lead to serious complications like sepsis, requiring immediate provider attention.

Choice D reason: Approximated wound edges indicate proper closure and healing, reducing scarring and infection risk. This positive finding does not warrant notification. Yellow purulent drainage, conversely, signals infection, a critical complication requiring urgent intervention to prevent further tissue damage or systemic infection, making it the priority.

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Correct Answer is A

Explanation

Choice A reason: Persistent pain after Herpes zoster suggests postherpetic neuralgia (PHN), a neuropathic condition from varicella-zoster virus damaging sensory nerves. Assessing pain intensity, location, and characteristics guides treatment with analgesics or anticonvulsants like gabapentin. This step differentiates PHN from other causes, ensuring targeted therapy to alleviate nerve pain and improve quality of life.

Choice B reason: Checking shingles vaccination status is irrelevant for current pain, as the client already had Herpes zoster. Vaccination prevents initial infection but does not treat PHN, which results from nerve damage during active infection. Pain assessment is critical to address neuropathic symptoms caused by viral-induced sensory nerve dysfunction, making this less urgent.

Choice C reason: A mental status exam evaluates cognition but is not indicated for PHN, a physiological condition from nerve damage, not a cognitive issue. Pain is neuropathic, driven by damaged sensory neurons, not psychological factors. Assessing pain directly addresses the client’s complaint, guiding treatment for nerve-related discomfort, making this action inappropriate.

Choice D reason: Teaching about phantom pain is incorrect, as phantom pain occurs post-amputation, not after shingles. PHN involves persistent nerve pain in the affected dermatome due to viral nerve damage. Misdiagnosing this could delay proper management, as pain assessment is needed to confirm PHN and initiate therapies like gabapentin, not phantom pain education.

A. Take the medication on an empty stomach. B. Report any signs of gastrointestinal bleeding. C. Wear a high intensity sunblock when outside. D. Monitor blood pressure frequently.

Correct Answer is B

Explanation

Choice A reason: Taking ibuprofen on an empty stomach increases gastrointestinal irritation, as NSAIDs inhibit prostaglandins, reducing gastric mucus protection. This risks gastritis or ulcers. Taking it with food minimizes irritation, making this instruction incorrect and potentially harmful for clients managing chronic arthritic pain with ibuprofen.

Choice B reason: Ibuprofen, an NSAID, risks gastrointestinal bleeding by inhibiting prostaglandins, weakening stomach lining protection, and impairing platelet aggregation. Symptoms like black stools or hematemesis indicate serious complications. Reporting these ensures early intervention, preventing severe outcomes like perforation or anemia, making this a critical instruction for safe use.

Choice C reason: High-intensity sunblock is relevant for photosensitizing drugs (e.g., doxycycline), not ibuprofen, which does not significantly increase photosensitivity. NSAIDs primarily affect cyclooxygenase pathways, not skin UV sensitivity. Reporting gastrointestinal bleeding is more critical, as it addresses a common, severe side effect requiring urgent attention.

Choice D reason: Ibuprofen can elevate blood pressure via sodium retention and vasoconstriction, but this is less common at standard doses. Gastrointestinal bleeding is a more frequent, severe risk, as NSAIDs disrupt gastric mucosa. Reporting bleeding symptoms takes precedence to prevent life-threatening complications, making blood pressure monitoring secondary.

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The nurse is changing a client’s abdominal surgical dressing. Which finding warrants notification to the healthcare provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Five months following treatment for Herpes zoster (shingles), an older adult client tells the home health nurse of continuing to experience pain where the rash occurred. Which action should the nurse implement?

Correct Answer is A

Explanation

Which instruction should the nurse include in the discharge teaching plan of a client who is prescribed ibuprofen for arthritic pain?

Correct Answer is B

Explanation

A client with a history of atrial fibrillation is prescribed warfarin. The nurse notes the client’s INR is 4.8. Which action should the nurse take? Reference Range: INR [2.0 to 3.0 for atrial fibrillation].

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