A wound has a blood-tinged liquid that is dripping from the surgical site. How does the nurse document this finding?

Correct Answer: C

Rationale: In this scenario, the nurse should document the blood-tinged liquid from the wound as serosanguineous. Serosanguineous exudate is a common type of wound drainage that is a combination of blood and clear fluid. This type of drainage is expected in the immediate postoperative period and indicates normal healing. The option A, "creamy pus," is incorrect because it describes purulent exudate, which is thick, opaque, and typically yellow or green in color, indicating infection. Option B, "serous," is incorrect as serous drainage is clear and watery, without blood. Option D, "purulent exudate," is also incorrect as it describes pus, a sign of infection. From an educational perspective, understanding different types of wound drainage is crucial for nurses to assess wound healing and detect signs of infection early. Proper documentation of wound drainage helps healthcare providers track changes in the wound, monitor healing progress, and determine appropriate interventions. Nurses need to be able to accurately differentiate between different types of wound exudate to provide optimal care for their patients.

Correct Answer: C

Rationale: The correct answer is C) "Bleeding and swelling cause increased pressure in an area that cannot expand." Compartment syndrome occurs when there is increased pressure within a closed muscle compartment, leading to decreased blood flow, which can result in tissue damage. In the case of a severely fractured arm, bleeding and swelling can accumulate within the compartment, causing pressure to build up. Option A is incorrect because it describes fascial expansion, which is not the primary cause of compartment syndrome. Option B is incorrect as impaired arterial perfusion is a consequence rather than a cause of compartment syndrome. Option D is incorrect as nerve injury is not the main mechanism behind compartment syndrome. Educationally, understanding the pathophysiology of compartment syndrome is crucial for nurses caring for patients with traumatic injuries. By grasping how bleeding and swelling lead to increased pressure within muscle compartments, nurses can promptly recognize and intervene in cases of compartment syndrome to prevent further tissue damage and complications. This knowledge is vital in providing optimal care and improving patient outcomes in orthopedic and trauma settings.

Correct Answer: C

Rationale: The correct answer is the client on Methotrexate with a fever. Fever in a client on Methotrexate, an immunosuppressant, could indicate a serious infection or adverse drug reaction requiring immediate attention to prevent complications. The other choices do not present immediate life-threatening concerns. A client with lupus asking for dinner can wait, a client with chronic rheumatic pain may need pain management but is not the priority over a fever in a client on Methotrexate, and a client with children visiting does not pose an urgent medical issue.

Correct Answer: C

Rationale: In the scenario of a client with a femur fracture, the nurse's priority assessment should be checking the pedal pulses (Option C). This is crucial to evaluate the perfusion and circulation to the lower extremities, especially in the case of a femur fracture where there is a risk of impaired blood flow due to trauma or associated injuries. Without adequate blood flow, the client may be at risk for complications like ischemia or compartment syndrome, which could lead to further damage or even amputation. Option A, pain assessment, is important but would typically come after ensuring adequate circulation and perfusion to the extremity. Pain can be managed once the client's circulation status is stable. Option B, medication history, while relevant for overall care, is not the immediate priority in this situation where assessing perfusion and circulation takes precedence. Option D, socio-economic status, is not directly related to the immediate assessment needed for a client with a femur fracture. While social factors are important in holistic care, they do not take precedence over the client's physiological needs in this acute situation. Educationally, understanding the rationale behind prioritizing assessments based on the client's condition is crucial for nurses to provide safe and effective care. It highlights the importance of critical thinking and clinical judgment in prioritizing interventions to address the most life-threatening issues first.

Correct Answer: A

Rationale: The correct answer is A) Shearing or friction. When a client sustains an injury to the heel while being moved in bed, shearing or friction forces are the most likely cause. Shearing occurs when tissues move in opposite directions, causing layers of tissue to stretch and tear. Friction can also contribute to skin breakdown and injury when there is excessive rubbing or sliding of the skin against a surface. Option B) Twisting and bending, is incorrect in this context because these forces are more likely to cause musculoskeletal injuries rather than a heel injury related to movement in bed. Option C) Pressure or gravity, while important factors in healthcare and patient care, are not the primary forces at play when discussing an injury to the heel during movement. Pressure ulcers may result from sustained pressure over bony prominences, but in this scenario, the injury is more likely due to shearing or friction forces. Option D) Chemical or pressure are also not relevant in this context of a heel injury during movement in bed. Educationally, understanding the mechanisms of injury related to patient movement is crucial for healthcare providers to prevent harm and ensure patient safety. Proper techniques, equipment use, and communication between healthcare team members can help mitigate risks associated with patient transfers and positioning. This knowledge is vital in promoting safe and effective care for patients in various healthcare settings.