Pain & Wound Care Part 2

The nurse is collecting data on a patient experiencing pain. Which of the following objective symptoms would the nurse observe and document?

a. Restlessness b. Frowning c. Clenched fists

A nurse is collecting data on a client's wound. The nurse observes that the wound surface is covered with soft, red tissue that bleeds easily. The nurse should recognize this is a manifestation of which of the following?

granulation tissue

What is the primary reason for a client using cold compress?

it decreases edema to the site

The nurse reminds the client that primary intention has a marked advantage over other phases of wound healing in that:

minimal scarring results.

A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects the client's wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found?

Purulent

In an attempt to keep the client comfortable during a dressing change, the nurse may administer an analgesic:

30 minutes BEFORE any dressing changes

The nurse carefully measures drainage during the first twenty four hours post surgery. The nurse is aware that it is considered abnormal if the drainage exceeds

300 mL

A nurse is changing the dressing on a client's wound. The nurse should recognize which of the following findings is an indication of a wound infection?

Edema

A nurse is assisting with the care of a client who is postoperative and has a closed-wound drainage system in place. Which of the following actions should the nurse take?

Fully re-collapse the reservoir after emptying it.

A nurse is caring for a client who has a large wound that has a vacuum-assisted closure device placed over it. Which of the following findings by the nurse indicates healing of the wound?

Granulation tissue on the surface of the wound