When changing the client's dressing for a vacuum-assisted closure (VAC) wound therapy system, the nurse observes foul, purulent drainage.
Which intervention(s) should the nurse implement? Select all that apply.

Document the wound measurements with tunneling.

Cleanse the wound and discontinue the VAC system.

Increase the wound VAC suction to eliminate the drainage.

Consult the wound care specialist to evaluate the wound.

Reapply the VAC system after irrigating away drainage.

Answer and Explanation

Correct Answer : A,B,D

Choice A rationale

Documenting the wound measurements with tunneling is important for tracking the wound's progression and planning appropriate interventions. Accurate documentation helps in assessing the effectiveness of the treatment plan.

Choice B rationale

Cleansing the wound and discontinuing the VAC system is necessary when foul, purulent drainage is observed. This action helps to prevent further infection and allows the healthcare provider to reassess the wound care approach.

Choice D rationale

Consulting the wound care specialist to evaluate the wound is essential for expert advice on managing complex wounds. Specialists can provide tailored recommendations to promote wound healing and prevent complications.

Choice C rationale

Increasing the wound VAC suction to eliminate the drainage is not appropriate as it may worsen the infection or damage the surrounding tissues. Proper wound care protocols should be followed to ensure safe and effective treatment.

Choice E rationale

Reapplying the VAC system after irrigating away drainage is not advisable if there is evidence of infection. The wound should be thoroughly assessed, and appropriate measures should be taken to address the underlying infection.

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

Explanation

Choice A rationale: Involving the mother in the decision-making process can help reduce caregiver stress by sharing the responsibility and ensuring that the client's preferences and needs are considered. This collaborative approach can lead to better outcomes and improved communication.

Choice B rationale: It is important to acknowledge that caregiving can be challenging and can affect emotions. Recognizing that it is okay to have complex feelings, including not always loving or liking the person being cared for, helps normalize these emotions and reduces guilt and stress.

Choice C rationale: Moving a loved one into a care facility can be a difficult decision, but it does not necessarily mean a lack of love. However, this statement is not appropriate as it may reinforce negative emotions and guilt.

Choice D rationale: Avoiding the discussion of negative situations that may occur in the future is not helpful. It is important to plan for potential challenges to be prepared and reduce stress.

Choice E rationale: Saying "no" to things involving the care of a loved one is not selfish. It is important to set boundaries and prioritize self-care to prevent caregiver burnout. However, this statement suggests the opposite and is not appropriate.

Choice F rationale: Taking time for oneself and maintaining other important relationships is essential for a caregiver's well-being. Self-care and social support can help reduce stress and improve the ability to provide care effectively.

A. Fetal decelerations B. Reports of pain C. Nausea D. Dizziness E. Hypotension F. Difficulty breathing

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

Explanation

Choice A rationale: Fetal decelerations require immediate action because they indicate potential fetal distress. Continuous fetal monitoring is essential to assess the fetus's well-being, and any signs of distress must be addressed promptly to ensure a safe delivery.

Choice E rationale: Hypotension is a common side effect of epidural anesthesia and can lead to decreased blood flow to the fetus. Immediate intervention, such as administering IV fluids or medications, is necessary to stabilize the mother's blood pressure and ensure adequate fetal perfusion.

Choice F rationale: Difficulty breathing is a critical sign that may indicate a severe reaction to the epidural anesthesia or other complications. Immediate assessment and intervention are required to ensure the mother's respiratory status is stable and to address any underlying issues.

Choice B rationale: Reports of pain, while important, do not require immediate emergency action compared to the other findings. Pain management should be adjusted accordingly, but it does not pose an immediate threat to the mother or fetus.

Choice C rationale: Nausea, while uncomfortable, is a common side effect of epidural anesthesia and does not require immediate emergency intervention. It can be managed with antiemetic medications.

Choice D rationale: Dizziness can be a side effect of epidural anesthesia or hypotension, but it is not as critical as the other findings that require immediate emergency attention. It should be monitored and addressed as part of overall care.

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When changing the client's dressing for a vacuum-assisted closure (VAC) wound therapy system, the nurse observes foul, purulent drainage. Which intervention(s) should the nurse implement? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an 84-year-old female client in her home and is discussing caregiver stress with the client’s daughter. Exhibits Select the 3 statements that the nurse should include when discussing caregiver stress with the client’s daughter.

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

Explanation

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

Explanation

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When changing the client's dressing for a vacuum-assisted closure (VAC) wound therapy system, the nurse observes foul, purulent drainage.
Which intervention(s) should the nurse implement? Select all that apply.