Which action should the nurse take after assessing a 2-day-old wound that has a crust along the edges, is red and appears slightly swollen?
Apply warm soaks to reduce the inflammation.
Notify the health care provider immediately of the infection.
Place the client on contact (wound) precautions.
Document the findings and continue to monitor the wound.
The Correct Answer is D
. Document the findings and continue to monitor the wound. This is because a 2-day-old wound that has a crust along the edges, is red and appears slightly swollen is likely in the inflammatory phase of wound healing. This phase is characterized by hemostasis, chemotaxis, and increased vascular permeability, which can
cause redness and swelling. The crust along the edges is formed by the clotting of blood and platelets.
These are normal signs of wound healing and do not indicate infection or complications.
Choice A is wrong because applying warm soaks to reduce inflammation can interfere with the natural process of wound healing and increase the risk of infection.
Choice B is wrong because notifying the health care provider immediately of the infection is not necessary unless there are other signs of infection such as fever, pus, foul odor, or increased pain.
Choice C is wrong because placing the client on contact (wound) precautions is not required for a 2-day-old wound that is not infected or draining. Wound precautions are only indicated for wounds that are colonized or infected by multidrug-resistant organisms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
What are the client’s cultural norms? This question is important because it helps to assess whether the client’s behavior is influenced by their cultural background and values, which may differ from those of the staff and other clients.
For example, some cultures may value privacy, modesty, or respect for elders more than others, and may avoid eye contact or social interaction as a sign of politeness or deference.
Understanding the client’s cultural norms can help to provide culturally sensitive and appropriate care.
Choice A is wrong because it assumes that the client’s behavior is caused by negative interactions with other clients, which may not be the case.
Choice B is wrong because it assumes that the client’s behavior is caused by hostile thoughts about others, which may not be the case.
Choice C is wrong because it assumes that the client’s behavior is caused by fear of others in the unit, which may not be the case.
These choices are not relevant to planning the client’s care and may reflect bias or stereotyping on the part of the staff.
Correct Answer is C
Explanation
This is because renal calculi can cause renal colic, which is a sudden and intense pain in the flank area that radiates to the groin or testicles.
The pain is caused by the stone obstructing the ureter and triggering spasms.
Choice A is wrong because a feeling of pressure in the bladder is more likely to indicate a lower urinary tract infection or an overactive bladder.
Choice B is wrong because a mild, burning pain when urinating is more likely to indicate a urinary tract infection or a urethral injury.
Choice D is wrong because a constant, dull, aching pain in the right upper quadrant is more likely to indicate a liver or gallbladder problem.
Normal ranges for urine pH are 4.5 to 8.0, and for specific gravity are 1.005 to 1.030.
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