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 D

Explanation

Choice A reason: Reviewing vascular disease history provides context but does not confirm perfusion status. An absent DP pulse may indicate arterial occlusion, risking ischemia. Doppler assessment directly evaluates blood flow, detecting patency, critical for guiding interventions to ensure limb perfusion, making history review secondary.

Choice B reason: Marking an auscultated DP pulse is incorrect, as pulses are palpated or Doppler-assessed, not auscultated. Auscultation applies to heart or lungs. Doppler confirms arterial flow, addressing absent pulse’s potential occlusion, making this inaccurate compared to the precise Doppler technique.

Choice C reason: Capillary refill evaluates perfusion but is less specific than Doppler, which confirms arterial flow. Prolonged refill may indicate ischemia, but absent DP pulse suggests arterial compromise. Doppler acoustically detects flow, diagnosing critical limb ischemia, making it the priority over indirect perfusion measures.

Choice D reason: Using Doppler to assess DP pulse is critical, as an absent pulse may indicate occlusion from peripheral arterial disease, risking ischemia. Doppler detects blood flow, confirming patency or obstruction, guiding urgent interventions like angiography, ensuring limb viability by addressing vascular compromise directly.

A. Withhold the dose until insulin regular is available on the unit. B. Withdraw 10 units regular insulin from the 70/30 vial. C. Pull up 30 units from the 70/30 vial, but only administer one third. D. Obtain a new vial of regular insulin and withdraw 10 units.

Correct Answer is D

Explanation

Choice A reason: Withholding the dose delays glucose control, risking hyperglycemia. Obtaining regular insulin ensures accurate dosing, as 70/30 cannot be separated. Timely administration is critical, per diabetes management and insulin therapy protocols in nursing practice for glycemic control.

Choice B reason: Withdrawing regular insulin from a 70/30 vial is impossible, as it’s a fixed mixture. Obtaining a regular insulin vial ensures precise 10-unit dosing, preventing errors, per medication safety and insulin administration standards in diabetes nursing care.

Choice C reason: Pulling 30 units of 70/30 and giving one third is unsafe, as it delivers mixed insulins, not just regular insulin. Obtaining regular insulin ensures accurate dosing, per insulin therapy and patient safety protocols in diabetes management nursing practice.

Choice D reason: Obtaining a new vial of regular insulin ensures the precise 10-unit dose, as 70/30 is a fixed mixture unsuitable for separating regular insulin. This prevents dosing errors, per evidence-based insulin administration and medication safety standards in diabetes nursing care.

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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

While completing an admission assessment, the nurse is unable to palpate the client’s left dorsalis pedis (DP) pulse. Which intervention is most important for the nurse to implement?

Correct Answer is D

Explanation

Based on the capillary glucose measurement, a client is to receive 10 units of regular insulin. The client’s medication drawer contains one vial of a 70/30 mixture of regular insulin and isophane insulin. How should the nurse prepare the prescribed dose?

Correct Answer is D

Explanation

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