Nokea
Which of the following orders would you expect the health-care provider to write after receiving laboratory results for the patient in Question 20?
- A. Bedrest with bathroom privileges
- B. Discharge tomorrow morning
- C. Wound culture and sensitivity
- D. Low-protein diet
Correct Answer: C
Rationale: A wound culture and sensitivity test is appropriate to identify the specific bacteria and effective antibiotics for an infected wound.
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You are caring for a patient with several risk factors for a pressure injury. Which would you avoid when caring for this patient?
- A. Pulling the sheets from beneath the patient so she does not have to turn frequently.
- B. Turning the patient using a lift sheet to prevent her from sliding on the sheets.
- C. Padding the bony prominences to help prevent pressure that could impair circulation.
- D. Turning the patient at least every 2 hours to prevent prolonged pressure in one area.
Correct Answer: A
Rationale: Pulling sheets can cause shear and friction, increasing pressure injury risk. The other options are preventive measures.
Which of these factors affect wound healing?
- A. Positive attitude
- B. Chronic illness
- C. Medications
- D. Atmospheric pressure
- E. Diabetes mellitus
- F. Age
Correct Answer: B,C,E,F
Rationale: Chronic illness, medications, diabetes, and age impair immune response, tissue repair, or blood flow, delaying wound healing.
A patient with an open leg wound has the following laboratory results on his chart: WBC 15,350 mm^3 with an elevated percentage of neutrophils. What does this tell you about the patient's wound?
- A. He most likely no longer has any wound infection.
- B. He most likely has an acute wound infection.
- C. He most likely has a chronic wound infection.
- D. He most likely has a widespread bacterial infection.
Correct Answer: B
Rationale: Elevated WBC and neutrophils indicate an active immune response, typically seen in acute infections, suggesting the wound is acutely infected.
All of the following are found during your assessment of a surgical wound. Which would concern you the most?
- A. Edges of the wound are together except for a 1-cm area at the distal end, which is open approximately 1.5 cm.
- B. All sutures are intact, but one suture is somewhat looser than the other sutures.
- C. The 2-cm margin around the wound is red, warm, and swollen.
- D. The patient complains of increasing pain in the incisional area compared to yesterday.
Correct Answer: C
Rationale: Redness, warmth, and swelling around the wound margin are signs of infection, which is most concerning and requires prompt intervention.
The drainage in a patient's Jackson-Pratt drain is red and appears bloody. This drainage is described as
- A. Serosanguineous
- B. Sanguineous
- C. Serous
- D. Purulent
Correct Answer: B
Rationale: Sanguineous drainage is characterized by red, bloody fluid, typically seen in fresh wounds or surgical drains like a Jackson-Pratt drain.