Free NCLEX-RN Exam Braindumps (page: 249)

Page 249 of 431

The nurse documents a client's surgical incision as having red granulated tissue. This indicates that the wound is:

  1. Infected
  2. Not healing
  3. Necrotic
  4. Healing

Answer(s): D

Explanation:

(A) The wound is not infected. An infected wound would contain pus, debris, and exudate. (B) The wound is healing properly. (C) A necrotic wound would appear black or brown. (D) The wound is healing properly and is filled with red granulated tissue and fragile capillaries.



The nurse documents a client's surgical incision as having red granulated tissue. This indicates that the wound is:

  1. Infected
  2. Not healing
  3. Necrotic
  4. Healing

Answer(s): D

Explanation:

(A) The wound is not infected. An infected wound would contain pus, debris, and exudate. (B) The wound is healing properly. (C) A necrotic wound would appear black or brown. (D) The wound is healing properly and is filled with red granulated tissue and fragile capillaries.



A client has just been transferred to the floor from the labor and delivery unit following delivery of a stillborn term infant. She is very despondent. When the nurse attempts to take her vital signs, she responds in anger, stating, "You leave me alone. You don't care anything about me. It's people like you who let my baby die." The nurse's best course of action is to:

  1. Quietly leave her room, allowing her more private time to deal with her loss.
  2. Tell her that what happened was for the best and that she is still young and can have other children.
  3. Tell her how sorry you are, and let her know that her child is now a little angel in heaven.
  4. Tell her how sorry you are about the loss of her baby, and acknowledge her anger as being a normal stage of grief. Assure her that you are there to help her in any way you can.

Answer(s): D

Explanation:

(A) Parents do need their privacy following a loss, but the nurse still has a responsibility to provide postpartum physical care. (B) This is a negative statement, which is not therapeutic. The client is not concerned about future children but is in the first stages of grief, denial, and anger. (C) This is a negative statement, which is not therapeutic. The client does not want to hear about her baby in heaven. She cannot believe that God could love or want her child more than she could. (D) Acknowledging that anger is normal and beneficial will help the client to understand the normal stages of grief. Expressing sorrow over her loss and assuring her that the support is there to take care of her physical and emotional needs will help to promote a trusting relationship.



A client has just been transferred to the floor from the labor and delivery unit following delivery of a stillborn term infant. She is very despondent. When the nurse attempts to take her vital signs, she responds in anger, stating, "You leave me alone. You don't care anything about me. It's people like you who let my baby die." The nurse's best course of action is to:

  1. Quietly leave her room, allowing her more private time to deal with her loss.
  2. Tell her that what happened was for the best and that she is still young and can have other children.
  3. Tell her how sorry you are, and let her know that her child is now a little angel in heaven.
  4. Tell her how sorry you are about the loss of her baby, and acknowledge her anger as being a normal stage of grief. Assure her that you are there to help her in any way you can.

Answer(s): D

Explanation:

(A) Parents do need their privacy following a loss, but the nurse still has a responsibility to provide postpartum physical care. (B) This is a negative statement, which is not therapeutic. The client is not concerned about future children but is in the first stages of grief, denial, and anger. (C) This is a negative statement, which is not therapeutic. The client does not want to hear about her baby in heaven. She cannot believe that God could love or want her child more than she could. (D) Acknowledging that anger is normal and beneficial will help the client to understand the normal stages of grief. Expressing sorrow over her loss and assuring her that the support is there to take care of her physical and emotional needs will help to promote a trusting relationship.



Page 249 of 431



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