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

Explanation

Choice A rationale

Reporting the client's jaw pain to the healthcare provider is crucial because jaw pain is a potential symptom of osteonecrosis of the jaw (ONJ), a rare but serious side effect of bisphosphonates like alendronate. ONJ involves the death of bone tissue in the jaw, leading to significant complications. Early intervention and management are essential to prevent further deterioration and address any underlying issues.

Choice B rationale

Determining how the client is administering the medication is important but not the immediate priority when addressing jaw pain, which could indicate a serious complication. Ensuring proper administration can prevent future issues but does not address the immediate concern of potential ONJ.

Choice C rationale

Advising the client to gargle with warm salt water twice daily may provide temporary relief from minor oral discomfort but is not appropriate for addressing potential osteonecrosis of the jaw. This suggestion does not address the underlying cause of jaw pain in a client taking bisphosphonates.

Choice D rationale

Confirming that jaw pain is a common symptom of osteoporosis is incorrect. While musculoskeletal pain can be associated with osteoporosis, jaw pain in a client taking alendronate may indicate osteonecrosis of the jaw, a serious condition requiring prompt medical attention.

A. Participation of community leaders in planning the program. B. Morbidity data for breast cancer in women of all races. C. A listing of African-American women who live in the community. D. Technical assistance to produce a video on breast self-examination.

Correct Answer is A

Explanation

Choice A rationale

Participation of community leaders in planning the program is crucial because these leaders have an in-depth understanding of the community's needs and concerns. Their involvement ensures that the program is culturally relevant and addresses the specific health disparities faced by African-American women. Additionally, community leaders can help foster trust and encourage participation from community members, making the program more effective.

Choice B rationale

While morbidity data for breast cancer in women of all races can provide valuable information on overall trends, it does not address the specific needs and challenges faced by African-American women. Focusing on the unique risks and barriers faced by this group is essential for designing an effective health promotion program.

Choice C rationale

A listing of African-American women who live in the community is useful for outreach and engagement but does not provide the essential insight needed to design a culturally sensitive and relevant program. Participation from community leaders is more effective in understanding and addressing the community's specific needs.

Choice D rationale

Technical assistance to produce a video on breast self-examination is valuable for education but is not the most important resource for designing a comprehensive health promotion program. The program must be tailored to the community's unique needs, which requires input from community leaders.

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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 female client is taking alendronate, a bisphosphonate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?

Correct Answer is A

Explanation

The nurse has received funding to design a health promotion project for African-American women who are at risk for developing breast cancer. Which resource is most important in designing this program?

Correct Answer is A

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.