While changing the dressing of a client who is immobile, the practical nurse (PN) 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 PN should evaluate 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
The correct answer is choice B. Culture for sensitive organisms.
Choice A rationale:
C-reactive protein (CRP) levels are indicative of inflammation in the body and can help identify the presence of an infection. However, CRP levels do not provide specific information about the type of organism causing the infection, which is crucial for targeted treatment.
Choice B rationale:
A culture for sensitive organisms is essential in this scenario because it identifies the specific bacteria or other pathogens present in the wound. This information is critical for selecting the appropriate antibiotic therapy to treat the infection effectively.
Choice C rationale:
Serum albumin levels are important for assessing nutritional status and overall health, which can impact wound healing. Low albumin levels can indicate poor nutritional status and delayed wound healing, but they do not provide immediate information about the infection itself.
Choice D rationale:
Serum blood glucose (BG) levels are crucial for managing diabetes and can affect wound healing. High blood glucose levels can impair the immune response and slow down the healing process. However, like CRP, BG levels do not provide specific information about the type of infection present in the wound.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The PN should directly observe the UAP's performance and provide feedback and guidance as needed. This can help ensure that the UAP follows the standards of care and respects the client's dignity and preferences.
The other options are not correct because:
A. Asking another UAP to help the oriented may not be appropriate or necessary, as it may interfere with the orientation process and create confusion or conflict.
B. Verifying with the client that the bath was complete and thorough may not be sufficient or reliable, as the client may not be able to assess the quality of care or may not want to complain.
C. Inspecting the client's skin near the end of the bathing procedure may not be timely or comprehensive, as it may miss some aspects of care or some problems that occurred during the bath.
Correct Answer is B
Explanation
Choice A rationale:
Asking the client to describe the intensity of the eye pain using the numerical pain scale is not the most relevant action in this situation. The client's statement indicates a misconception about the purpose of pilocarpine eye drops, so addressing this misunderstanding should be the focus.
Choice B rationale:
Reminding the client that the action of the eye drops is to decrease internal eye pressure is the appropriate action. Pilocarpine eye drops are used to treat glaucoma by reducing intraocular pressure, not to anesthetize the eye.
Choice C rationale:
Documenting in the chart that the client understands the action and use of the eye drops might be necessary but should not be the first action taken. The priority is to correct the client's misunderstanding about the eye drops.
Choice D rationale:
Clarifying with the client that eye pain in glaucoma is uncommon, so drops are rarely needed, is not accurate. While eye pain might not be a common symptom of glaucoma, pilocarpine eye drops are specifically used to manage intraocular pressure and are not intended to address eye pain.
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