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 B
Explanation
.“I need to receive 3 doses of hepatitis B vaccination to assure protection.” This statement indicates that the person understands that hepatitis B is a serious infection that can be prevented by vaccination.
Hepatitis B vaccine is given as a series of 3 shots over a period of 6 months.
Choice A is wrong because hepatitis A is not usually transmitted through unprotected sex, but through ingestion of contaminated food or water or direct contact with an infected person.
Hepatitis A can also be prevented by vaccination.
Choice C is wrong because hepatitis C can be transmitted through IV drug use, as well as blood transfusions, organ transplants, needlestick injuries, and sharing personal items such as razors or toothbrushes with an infected person.
Hepatitis C can cause chronic liver disease and there is no vaccine for it.
Choice D is wrong because there is a vaccine for hepatitis A, which can provide lifelong protection against the infection.
Hepatitis A usually does not require treatment and most people recover completely within a few weeks. There is no specific medication to cure hepatitis
Correct Answer is A
Explanation
Rhonchi. Rhonchi are low-pitched, rattling sounds that indicate mucus in the larger airways. They are most evident on expiration and may decrease after coughing.
Choice B is wrong because wheezes are high-pitched, squeaking sounds that indicate narrowed small air passages. They are usually heard on both inspiration and expiration.
Choice C is wrong because crackles are short, high-pitched popping sounds that indicate fluid or inflammation in the alveoli. They are usually heard on inspiration.
Choice D is wrong because pleural friction rubs are creaking or grating sounds that indicate inflammation of the pleura. They are usually heard on both inspiration and expiration and do not change with coughing.
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