While changing a client’s postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client’s laboratory values?
Serum blood glucose level.
Culture for sensitive organisms.
C-reactive protein level.
Blood pH level.
The Correct Answer is B
Choice A rationale
Serum blood glucose level is not directly related to the presence of purulent drainage at a wound site. While blood glucose levels can affect wound healing, they do not provide specific information about the presence of infection.
Choice B rationale
Culture for sensitive organisms is the most appropriate laboratory value to note when purulent drainage is observed. This test helps identify the specific bacteria causing the infection and determines the most effective antibiotics for treatment.
Choice C rationale
C-reactive protein (CRP) level is a marker of inflammation and can indicate the presence of an infection, but it does not provide specific information about the bacteria causing the infection.
Choice D rationale
Blood pH level is not directly related to the presence of purulent drainage at a wound site. While blood pH can be affected by severe infections, it is not a specific indicator of wound infection.
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Correct Answer is C
Explanation
Choice A rationale
Anxiety and grieving are important issues but are not the priority when the client is at risk for aspiration.
Choice B rationale
Chronic pain is significant, but the immediate risk of aspiration due to dysphagia takes precedence.
Choice C rationale
Risk for aspiration related to difficulty swallowing is the priority nursing problem. Aspiration can lead to serious complications such as pneumonia.
Choice D rationale
Imbalanced nutrition is important but is secondary to the immediate risk of aspiration.
Correct Answer is A
Explanation
Choice A rationale
Reviewing with the client the need to avoid foods rich in milk and cream is crucial. Dairy products can increase gastric acid secretion, which can exacerbate duodenal ulcers.
Choice B rationale
Suggesting frequent small meals can help reduce discomfort but does not address the issue of dairy products exacerbating the ulcer.
Choice C rationale
Switching to decaffeinated coffee and tea is beneficial but not as critical as avoiding dairy products.
Choice D rationale
Reinforcing teaching by asking the client to list dairy foods does not address the need to avoid these foods.