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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Inspection, palpation, percussion, and auscultation are the four techniques used to perform a physical assessment.
Inspection involves observing the patient’s appearance, posture, movement, and behavior. Palpation involves feeling the patient’s skin, organs and pulses with the hands.
Percussion involves tapping the patient’s body with the fingers or a small hammer to elicit sounds or vibrations.
Auscultation involves listening to the patient’s heart, lungs, and bowel sounds with a stethoscope.
Choice A is wrong because relationship and evaluation are not techniques of physical assessment.
Relationship refers to the rapport and trust established between the nurse and the patient.
Evaluation refers to the process of comparing the expected outcomes with the actual outcomes of the nursing interventions.
Choice C is wrong because vital signs, health history, general survey, and height and weight are not techniques of physical assessment.
They are components of a health assessment, which is a broader term that includes physical assessment as well as other aspects of the patient’s health status.
Choice D is wrong because color is not a technique of physical assessment.
Color is an aspect of inspection, which is one of the techniques of physical assessment.
Correct Answer is B
Explanation
This indicates that the client has a fluid volume deficit, which is consistent with the signs and symptoms of low urine output, weight gain, irritability, and headache. The normal range for serum osmolality is 275 to 295 mOsm/Kg.
Choice A is wrong because hemoglobin 15.3 mg/dL is within the normal range of 12 to 18 mg/dL and does not correlate with fluid imbalance.
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