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: Avolition in schizophrenia is lack of motivation for goal-directed tasks, linked to prefrontal dopamine deficits. Performing activities of daily living (e.g., hygiene) shows improved motivation, achieving the goal. This reflects enhanced frontal lobe function, addressing the negative symptom of avolition, critical for functional recovery in schizophrenia.

Choice B reason: Explaining answers to open-ended questions shows cognitive ability, not motivation. Avolition impairs initiative for tasks like self-care, not verbal skills. Schizophrenia’s negative symptoms reduce drive, and this behavior does not address the motivational deficit targeted, making it less relevant than performing daily activities.

Choice C reason: Reporting enjoyment suggests improved affect but not motivation. Avolition involves initiating tasks, not emotional response. Performing daily activities directly demonstrates overcoming avolition, a negative symptom of reduced drive, aligning with the goal of enhancing goal-directed behavior in schizophrenia, making this less indicative.

Choice D reason: Sharing a story indicates social engagement, impaired in schizophrenia but not specific to avolition, which affects motivation for routine tasks. Performing daily activities directly shows improved initiative, addressing the treatment goal’s focus on overcoming dopamine-related motivational deficits, making social sharing less relevant.

A. Administer oxygen per nasal cannula. B. Remove objects that could cause injury. C. Place pillows around the client’s head. D. Apply soft restraints to all extremities.

Correct Answer is B

Explanation

Choice A reason: Administering oxygen supports oxygenation but is not the priority during a seizure, typically brief without sustained hypoxia. Removing objects prevents trauma from tonic-clonic movements, driven by neuronal hyperexcitability, addressing the immediate risk of fractures or head injuries during uncontrolled muscle activity.

Choice B reason: Removing objects prevents injury during a seizure, as tonic-clonic convulsions from excessive neuronal discharges risk trauma like fractures. Ensuring a safe environment addresses the physiological risk of harm from environmental hazards, critical for protecting the client during uncontrolled movements in seizure activity.

Choice C reason: Placing pillows around the head may reduce injury but is less effective than clearing hazards, as seizures involve full-body movements. Pillows may not stay secure during clonic jerking. Removing objects ensures broader safety, minimizing trauma risk across all body areas, making this less immediate.

Choice D reason: Applying restraints is contraindicated, as they risk injury like fractures by resisting forceful neuronal-driven movements. Seizures require safe movement in a clear environment. Removing objects prevents trauma, addressing the physiological need for safety during a seizure, making restraints inappropriate and potentially harmful.

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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

The mental health team working with a homeless client with chronic schizophrenia establishes the treatment goal of, “Improvement in avolition prior to discharge.” Which behavior demonstrates achievement of this goal to the nurse?

Correct Answer is A

Explanation

After placing a client who is having a seizure in the side-lying position, which intervention should the nurse implement?

Correct Answer is B

Explanation

Following admission for a cardiac catheterization, the nurse is providing discharge teaching to the parents of a 2-year-old toddler with Tetralogy of Fallot. Which instruction should the nurse give the parents if their child becomes pale, cool, and lethargic?

The parents of a male infant newborn have signed an informed consent for circumcision. Which priority intervention should the nurse implement upon completion of the circumcision procedure?

A client has a prescription for the insertion of a nasogastric tube to low intermittent suction. When inserting the nasogastric tube, the nurse observes an immediate return of “coffee ground” drainage. Which action should the nurse implement?

After suctioning a client who has an endotracheal tube, which assessment finding indicates to the nurse that the intervention was effective?

A child is being prepared for a computed tomography (CT) scan when the child begins to have a tonic-clonic seizure. The mother is hysterical and is trying to hold the child down. What action(s) should the nurse take? (Select all that apply)

Four hours following surgical repair of a compound fracture of the right ulna, the nurse is unable to palpate the client’s right radial pulse. Which action should the nurse take first?

A client with gastroesophageal reflux disorder (GERD), who has been self-medicating with famotidine for the past week, is admitted to the acute care center because the symptoms have worsened. The nurse should anticipate which treatment?