The nurse provides care for a patient with an infected surgical wound. The nurse assesses the wound and changes the dressing. Which does the nurse include in the documentation? Select all that apply.

Presence of exudate

A number of sutures

Approximation of edges

Time of last antibiotic

Color of the wound bed

Answer and Explanation

Correct Answer : A,C,E

a. Presence of exudate: The presence and amount of exudate can indicate the severity of the infection and the eﬀectiveness of treatment.

c. Approximation of edges: This refers to how well the edges of the wound are coming together and healing, which is important in evaluating the progress of healing.

e. Color of wound bed: The color of the wound bed can also indicate the severity of infection and the eﬀectiveness of treatment.

Therefore, the correct answers are a, c, and e.

The number of sutures and the time of the last antibiotic are important information for the nurse to know, but they do not need to be included in the documentation of the wound assessment and dressing change.

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Correct Answer is C

Explanation

The client's statement of avoiding people because of having scabies and difficulty walking indicates that the client may be experiencing social isolation and loneliness. Loneliness is a significant concern for clients as it can lead to depression, anxiety, and other negative health outcomes. The other options, such as the potential for falls, injury, and self-neglect, may also be concerns for the client but are not indicated as the greatest concern in this scenario based on the information provided. Therefore, the nurse should document the client's greatest concern as the potential for loneliness.

A. Productive cough B. Heart rate 112 beats/min C. Blood pressure 96/52 mm Hg D. Weight gain of 2 kg (4.4 lb) E. Edema +2 of bilateral ankles and feet

Correct Answer is ["A","D","E"]

Explanation

These are all signs of ﬂuid volume overload. Measuring the client's intake and output can help the nurse monitor the client's ﬂuid balance and detect any imbalances. A productive cough may indicate ﬂuid accumulation in the lungs.

Weight gain and edema are also signs of ﬂuid retention.

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The nurse provides care for a patient with an infected surgical wound. The nurse assesses the wound and changes the dressing. Which does the nurse include in the documentation? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse plans care for a client who reports avoiding people because of having scabies and difficulty walking. Which statement does the nurse document as the client's greatest concern?

Correct Answer is C

Explanation

The nurse provides care for a client recovering from a motor vehicle crash. For which sign of ﬂuid volume overload does the nurse measure the client's intake and output? (Select all that apply)

Correct Answer is ["A","D","E"]

Explanation

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The nurse provides care for a patient with an infected surgical wound. The nurse assesses the wound and changes the dressing. Which does the nurse include in the documentation? Select all that apply.

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