Which term should the nurse use to document a raised, fluid-filled lesion smaller than 1 centimeter?

Macule

Vesicle

Papule

Wheal

Answer and Explanation

The Correct Answer is B

A.   Macule: A macule is a flat, discolored area of skin that is smaller than 1 centimeter in diameter and does not contain fluid.
B.   Vesicle: A vesicle is a raised, fluid-filled lesion smaller than 1 centimeter in diameter.
Examples include blisters caused by conditions such as herpes simplex virus or contact dermatitis.
C.   Papule: A papule is a raised, solid lesion smaller than 1 centimeter in diameter that does not contain fluid. Examples include pimples or insect bites.
D.   Wheal: A wheal is a raised, red area of skin that is often accompanied by itching. It is typically caused by an allergic reaction and may have irregular borders.

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Correct Answer is C

Explanation

A. Exudate: Exudate refers to the fluid, such as pus or serum, that is discharged from a wound.
While exudate may be present in infected wounds, it is not a systemic response.
B. Pain: Pain is a localized response to tissue injury and may be present in infected wounds, but it is not a systemic response.
C. Hyperthermia: Hyperthermia, or an elevated body temperature (fever), is a common systemic response to infection, including wound infections. It indicates the body's immune response to the infection.
D. Hardening of the tissue: Hardening of the tissue, known as induration, may occur in infected wounds due to inflammation but is not a specific systemic response.

A. "A culture identifies an antibiotic's effect on a pathogen." B. "A culture determines the appropriate medication dose." C. "A culture measures antibiotic levels." D. "A culture identifies the presence of pathogens."

Correct Answer is D

Explanation

A. "A culture identifies an antibiotic's effect on a pathogen.": Cultures do not determine the effect of antibiotics on pathogens; they identify the presence of pathogens and their susceptibility to antibiotics.
B. "A culture determines the appropriate medication dose.": Cultures do not determine medication doses; they identify pathogens and guide antibiotic selection based on susceptibility testing.
C. "A culture measures antibiotic levels.": Cultures do not measure antibiotic levels; they identify pathogens and their susceptibility to antibiotics.
D. "A culture identifies the presence of pathogens.": This is the correct explanation. A wound culture is performed to identify any microorganisms present in the wound, such as bacteria or fungi, which helps guide appropriate treatment.

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Which term should the nurse use to document a raised, fluid-filled lesion smaller than 1 centimeter?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a wound on their leg. During the nurse's assessment, the client explains that he is not feeling well. The nurse knows that a systemic response to a wound infection would be?

Correct Answer is C

Explanation

The nurse is collecting a culture of a wound. During the procedure, the patient asks what is a culture? Which of the following is the best response by the nurse to explain why she is culturing the wound?

Correct Answer is D

Explanation

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Which term should the nurse use to document a raised, fluid-filled lesion smaller than 1 centimeter?

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