The nurse is caring for a patient with a large open wound. While changing the dressing, the nurse notes purulent drainage
What additional assessments are necessary for this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Wound odor
2. Blood urea nitrogen (BUN)
3. Fever
4. Wound bleeding
5. White blood cell count
1,3,5
Rationale 1: The presence of an odor can be one of the first signs of impending infection.
Rationale 2: BUN is an indicator of renal function, not wound infection.
Rationale 3: Fever is an indicator of infection.
Rationale 4: Bleeding is not an indicator of infection.
Rationale 5: Purulent drainage indicates infection, which requires the nurse to assess for other indicators of infection. Increased WBC is a positive indicator of infection.
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A male inpatient client who is experiencing depression has no interest in eating. He skips meals frequently and has been losing weight. What is the best nursing action in this situation?
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Which statement is true about the physiologic effects of pain in labor?
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An appropriate procedure for the nurse to implement for the application of an absorption or alginate dressing is to:
A. Never cut the dressing to fit the wound B. Irrigate the wound gently to remove residual gel C. Fill the wound cavity entirely with the dressing material D. Dispose of old dressings in the waste container in the client's room