What is the priority assessment for a patient with an open wound that has a foul-smelling exudate?
Check the patient's blood sugar levels.
Assess for signs of systemic infection.
Measure the wound dimensions.
Apply a new dressing over the wound.
The Correct Answer is B
A. Check the patient's blood sugar levels: This is an important step in assessing a diabetic patient whose high blood sugar can impair healing, but it is not the most immediate priority for an actively infected wound.
B. Assess for signs of systemic infection: A foul odor (purulent drainage) indicates a localized infection. The priority is to assess if that infection is spreading systemically (sepsis) by checking for signs like fever, tachycardia, hypotension, and altered mental status. This assessment dictates the urgency of treatment (e.g., blood cultures, IV antibiotics).
C. Measure the wound dimensions: This is a routine, necessary step for wound documentation but is secondary to assessing the patient's immediate physiological status and the risk of life-threatening sepsis.
D. Apply a new dressing over the wound: This is an expected intervention but is secondary to a thorough assessment for systemic involvement, which guides immediate medical interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Mechanical debridement: This involves using a wet-to-dry dressing or wound irrigation. It is non-selective (can damage healthy tissue) and not the most rapid method, especially for heavily infected wounds.
B. Autolytic debridement: This uses the body's own enzymes (via moisture-retentive dressings like hydrocolloids) to break down necrotic tissue. It is slow and generally contraindicated in heavily infected wounds because sealing the wound can create an anaerobic environment, potentially worsening the infection.
C. Surgical debridement: Surgical (sharp) debridement is the fastest and most effective method for removing large amounts of non-viable, infected, and exudative tissue. A heavily infected wound needs immediate reduction of the bioburden, which surgical debridement achieves quickly, moving the wound toward the healing phase.
D. Enzymatic debridement: This uses topical chemical enzymes (e.g., collagenase). It is slower than surgical debridement and often less effective at rapidly clearing the large amount of debris expected in a heavily exudative, infected wound.
Correct Answer is D
Explanation
A. Increase the frequency of wound dressing changes:This is an appropriate measure to manage exudate and clean the wound, but it is not the highest priority action for treating the underlying infection.
B. Initiate contact isolation precautions:This is necessary if the organism requires isolation (e.g., MRSA), but it is a safety measure, not the clinical priority for treating the patient's infection.
C. Apply a non-adherent dressing:This is an appropriate dressing choice for a healing wound, but the priority is treating the infection itself.
D. Administer prescribed antibiotics:An infected Stage 3 pressure ulcer (confirmed or highly suspected) requires systemic treatment. Administering the prescribed antibiotic is the most critical intervention to prevent the localized infection from escalating to a systemic infection (sepsis) and to eliminate the bacteria that are stalling the healing process.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.