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 level - C-reactive protein (CRP) is a blood test marker for inflammation in the body. While it could indicate an infection, it is not specific enough to identify the type of infection or the causative organism.
- Choice B rationale:
- Culture for sensitive organisms - When a wound has a moderate amount of yellow and green drainage and a foul odor, it is often a sign of a bacterial infection. A culture for sensitive organisms can help identify the specific bacteria causing the infection, which is crucial for determining the most effective treatment.
- Choice C rationale:
- Serum albumin - Serum albumin levels can indicate a person’s nutritional status. Low levels can slow wound healing, but they do not directly indicate the presence of an infection.
- Choice D rationale:
- Serum blood glucose (BG) level - High blood glucose levels can impair the immune response and slow wound healing, making a person more susceptible to infections. However, like CRP, it does not provide information about the specific organism causing the infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The PN should not prioritize bringing a glucometer to the room in this situation. The client's unresponsiveness indicates a potential medical emergency that requires immediate action, and checking blood glucose levels is not the primary concern at this moment.
Choice C rationale:
Feeling for a carotid pulse is an essential step in assessing the client's circulation. However, it is not the first priority when the client is unresponsive. The PN should focus on obtaining emergency help first to ensure timely intervention.
Choice D rationale:
Checking the blood pressure can provide valuable information about the client's condition, but it is not the most critical step when dealing with an unresponsive client. Promptly seeking emergency assistance is more important to address the immediate concern.
Correct Answer is B
Explanation
Ask the client to describe what happened.
Calling the agency-based client advocate (Choice A) should not be the first action taken in this situation. While involving an advocate might be necessary at some point, it is more appropriate to address the client's concerns and gather information about the incident first.
Completing a client adverse incident report (Choice C) is an important step to document theevent and any potential issues, but it should not be the first action taken. Before completing the report, the nurse needs to understand the situation from the client's perspective.
Informing the charge nurse of the situation (Choice D) is a reasonable step, but it should not be the first action. It may be necessary to escalate the issue, but understanding the situation from the client's viewpoint should be prioritized.
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