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How will the nurse and Sam know that the treatment plan has been effective? Select all that apply.
- A. The current wounds become smaller and show signs of healing.
- B. Sam only occasionally has a fever and other signs of infection.
- C. Sam is satisfied with the plan and expresses understanding and adherence.
- D. Sam's partner can identify the early signs and symptoms of infection.
- E. Sam can walk a mile without getting short of breath.
Correct Answer: A,C,D
Rationale: Effective treatment is indicated by wound healing (A), patient satisfaction and adherence (C), and partner's ability to recognize infection signs (D). Occasional fever (B) suggests persistent infection, and walking a mile (E) is unrelated to wound healing outcomes.
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A patient was in an automobile accident and received a wound across the nose and cheek. After surgery to repair the wound, the patient says, 'I am so ugly now.' Based on this statement, psychosocial problem will the nurse plan to address?
- A. Pain
- B. Wound healing
- C. Body image
- D. Change in cognition
Correct Answer: C
Rationale: The patient's statement reflects concern about their appearance or indicating a body image issue requiring that needs psychosocial support.
A nurse on a surgical unit has assessed and documented a patient's wound and drainage. Which statements most accurately describe the characteristic of the wound drainage?
- A. Sanguineous drainage is composed of the clear portion of the blood and serous membranes.
- B. Sanguineous drainage is composed of a large number of red blood cells and looks like blood.
- C. Sanguineous drainage is composed of white blood cells, dead tissue, and bacteria.
- D. Sanguineous drainage is thin, cloudy, and watery and may have a musty or foul odor.
Correct Answer: B
Rationale: Sanguineous drainage consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. Serous drainage, generally watery, is composed primarily of the clear, serous portion of the blood and serous membranes. Purulent drainage is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. It is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism.
Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise as well as pain with redness at the surgical site. Which action is most appropriate?
- A. Documenting the findings and continuing to monitor the patient
- B. Administering antipyretics and contacting the provider for an antibiotic prescription
- C. Increasing the frequency of assessment to every hour and notifying the patient's primary care provider
- D. Obtaining a wound culture and increasing the frequency of wound care
Correct Answer: A
Rationale: The assessment findings are normal for this stage of healing following surgery. The patient is in the inflammatory phase of the healing process, which involves a response by the immune system. This acute inflammation is characterized by pain, heat, redness, and swelling at the site of the injury (surgery, in this case). The patient also has a generalized body response, including a mildly elevated temperature, leukocytosis, and generalized malaise.
What interventions are most likely to be effective in engaging Sam in their treatment and prevention plan? Select all that apply.
- A. Having Sam perform a return demonstration on active range of motion and repositioning
- B. Facilitating the interaction with the wound care specialist and reinforcing any teaching points
- C. Involving Sam's partner (with Sam's permission) in the dressing changes to increase their confidence before discharge
- D. Providing a pressure-relief support surface for the bed and chair that Sam agrees to use
- E. Instructing Sam on how to use the call bell and television remote in the room
Correct Answer: A,B,C,D
Rationale: Engaging Sam involves active participation (A), specialist interaction with reinforcement (B), involving the partner for support (C), and using a pressure-relief surface to prevent further wounds (D). Teaching about the call bell and remote (E) is less relevant to wound care engagement.
The nurse has 10 minutes before having to leave the room and administer blood to another patient. Which intervention is the priority for Sam?
- A. Sitting quietly with Sam
- B. Contacting Sam's partner and providing an update
- C. Consulting wound care for a thorough assessment
- D. Hanging the prescribed antibiotic
Correct Answer: D
Rationale: Hanging the prescribed antibiotic is the priority intervention given the diagnosed osteomyelitis, a serious bone infection requiring prompt treatment to prevent further complications. This takes precedence over emotional support, family updates, or wound care consultation within the 10-minute timeframe.