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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Questioning about related symptoms (e.g., urgency, frequency) clarifies nocturia and hesitancy, suggesting causes like benign prostatic hyperplasia. This comprehensive data guides targeted assessments, ensuring accurate diagnosis and treatment, per urological assessment and patient history standards in elderly male nursing care.
Choice B reason: Palpating for an inguinal bulge assesses hernia, unrelated to nocturia or hesitancy. Questioning related symptoms better identifies urinary issues, guiding diagnosis. Hernias are not primary causes, per urological assessment and differential diagnosis protocols in nursing care for urinary complaints.
Choice C reason: Inspecting the meatus for abnormalities or discharge may follow but is less comprehensive than symptom questioning, which broadens the urinary history. Symptoms like hesitancy suggest internal issues, per urological assessment and benign prostatic hyperplasia diagnostic standards in nursing practice for elderly men.
Choice D reason: Observing scrotal swelling assesses testicular issues, not directly linked to nocturia or hesitancy. Questioning symptoms like weak stream or dribbling prioritizes urinary tract evaluation, per urological and geriatric assessment protocols in nursing care for male urinary symptoms.
Correct Answer is D
Explanation
Choice A reason: Ensuring oxygen and medications manages exacerbations in asthma, bronchitis, and emphysema, where airway inflammation obstructs breathing. These treat symptoms, not prevent infections. Vaccines reduce influenza and pneumococcus, major exacerbation triggers, providing specific immunity to prevent severe respiratory infections, making them a higher priority.
Choice B reason: Using tissues and handwashing reduces infection spread but is less effective than vaccines for preventing exacerbations in chronic lung diseases. Influenza and pneumococcus trigger severe bronchoconstriction or inflammation. Vaccines offer targeted protection against these pathogens, prioritizing prevention over general hygiene in high-risk clients.
Choice C reason: Avoiding crowded areas in colder months reduces viral exposure, which can exacerbate asthma or COPD via inflammation. Vaccines are more effective, providing specific immunity against influenza and pneumococcus, the most common triggers of severe exacerbations, making this less critical than vaccination for preventing respiratory complications.
Choice D reason: Annual flu and PPSV23 vaccines are critical for asthma, bronchitis, and emphysema, as these conditions increase severe infection risk. Influenza and pneumococcus trigger exacerbations via airway inflammation, risking hospitalization. Vaccines stimulate antibody production, reducing infection severity, making them the top preventive measure for chronic lung disease management.
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