While changing the dressing of a client who is immobile, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?
C-reactive protein level.
Culture for sensitive organisms.
Serum albumin.
Serum blood glucose (BG) level.
The Correct Answer is B
A. CRP is an acute-phase protein produced by the liver in response to inflammation. Elevated CRP levels indicate systemic inflammation or infection. Measuring the CRP level can help confirm the presence of an inflammatory process, such as infection, and monitor the severity of inflammation. However, while useful, CRP alone might not provide the complete picture needed for specific wound management.
B. Culturing the wound for sensitive organisms is crucial when an infection is suspected. This test will identify the specific bacteria or other pathogens causing the infection and determine their sensitivity to various antibiotics. This information is essential for choosing the appropriate treatment to address the infection effectively.
C. Serum albumin levels provide information about the client’s nutritional status and can reflect protein malnutrition. Low serum albumin levels can indicate poor wound healing due to inadequate protein levels, which affects tissue repair. While serum albumin is important for understanding overall nutritional status, it does not directly diagnose or confirm infection.
D. Blood glucose levels are important to monitor, especially in diabetic patients, as high blood glucose can impair wound healing and increase the risk of infections. However, blood glucose levels are more related to the client's ability to heal rather than directly identifying or managing an infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Using larger bags might help accommodate the gas more comfortably and reduce the need for making pinholes. However, this solution does not address the immediate issue of gas accumulation and may not be practical for all clients.
B. "Burping" the bag is a recognized technique for managing gas in colostomy bags. It involves opening the end of the bag slightly to release gas, which helps to prevent the bag from ballooning and causing discomfort. This method is effective and safe, as it is specifically designed to manage gas without compromising the integrity of the bag.
C. Making pinholes in the colostomy bag is not a recommended practice. Pinholes can lead to leakage and increase the risk of skin irritation or infection. While ensuring the pinholes are at the top might reduce some complications, it does not solve the fundamental issue and poses a risk to the client's health and hygiene.
D. Colostomy bags equipped with built-in gas release valves are designed specifically to manage gas accumulation safely and effectively. Informing the client about these specialized bags provides a practical solution to the problem of gas buildup and avoids the risks associated with making pinholes.
Correct Answer is D
Explanation
A. While protein levels are important in assessing overall nutritional status and can indicate conditions like malnutrition or liver disease, they are not the primary focus in the context of fever, dry mucous membranes, and skin turgor changes.
B. Hemoglobin levels are crucial for assessing anemia and overall oxygen-carrying capacity of the blood. Although dehydration can potentially concentrate hemoglobin levels, it is not the primary laboratory value to monitor in the context of the acute symptoms
C. The white blood cell count is important for diagnosing infections and understanding the body's response to illness. However, in this scenario, the primary concern is dehydration, which is not directly measured by WBC count. While an elevated WBC could indicate an infection contributing to the fever, it is not the primary laboratory value to monitor for fluid and electrolyte imbalances.
D. Sodium is a key electrolyte that can be significantly affected by dehydration. Dry mucous membranes, inelastic skin turgor, and a fever suggest potential fluid loss and dehydration, which can lead to imbalances in sodium levels. Monitoring sodium levels is crucial because dehydration often results in elevated sodium concentrations (hypernatremia), which can have serious implications for the client’s health.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
