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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. While assessing brain stem reflexes can provide valuable information about the neurological status of the client, it is not the immediate priority when preparing to move a client from bed to a chair. Brain stem reflexes are more relevant for assessing overall neurological function and response to stimuli, but they do not directly inform the safety and readiness of the client for physical activity.
B. Assessing the pupillary response is important for evaluating neurological function and consciousness levels. However, it is not directly related to assessing the client’s readiness to be moved from bed to a chair. Pupillary response does not provide specific information about the client’s hemodynamic stability or immediate readiness for physical activity.
C. Assessing the client’s blood pressure is crucial, especially after a stroke, as the client may be at risk for orthostatic hypotension (a sudden drop in blood pressure when standing up). Checking blood pressure helps ensure that the client is hemodynamically stable and can tolerate the change in position without risking dizziness, fainting, or other complications.
D. Offering the client the opportunity to void before getting out of bed is a practical measure to ensure comfort and avoid accidents. It helps prevent the need for the client to seek the bathroom immediately after being moved to the chair, which could be disorienting or potentially hazardous.

A. Determine if the expected outcomes were realistic. B. Obtain current client data to compare with expected outcomes. C. Review related professional standards of care. D. Modify the nursing interventions to achieve the client's goals.

Correct Answer is B

Explanation

A. Assessing whether the expected outcomes were realistic involves evaluating if the goals set in the plan of care were achievable given the client’s condition, resources, and constraints. While this is an important consideration, it is not the immediate next step after reviewing the expected outcomes.
B. After reviewing the expected outcomes, the next critical step is to gather and analyze current client data. This includes assessing the client’s current condition, symptoms, and responses to interventions. By comparing this data with the expected outcomes, the nurse can determine if the goals are being met, if they need adjustment, or if different interventions are required.
C. Reviewing professional standards of care involves understanding the accepted norms and guidelines for nursing practice. While important, this action typically precedes the direct evaluation of care and is part of ensuring that the care plan was developed and implemented according to professional guidelines.
D. Modifying nursing interventions is an action that might be required if the evaluation shows that the expected outcomes are not being met. However, this action is taken after evaluating the effectiveness of the current interventions by comparing client data with expected outcomes.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?

Correct Answer is B

Explanation

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