A nurse is assessing a client who was brought to the emergency department with an ankle injury.
Which of the following manifestations should the nurse identify as localized inflammation of the tissues?

3+ palpable pedal pulses below the affected injury site.

Full range of motion at the site of injury.

Sanguineous drainage at the site of injury.

Localized warmth at the site of injury.

Answer and Explanation

The Correct Answer is D

Localized warmth at the site of injury is a sign of localized inflammation of the tissues, which is a response to tissue damage caused by an ankle injury. Localized inflammation involves changes in blood flow, vessel permeability, and leukocyte migration to the site of injury. Heat is one of the five classic signs of acute local inflammation, along with redness, swelling, pain, and loss of function.

Choice A is wrong because 3+ palpable pedal pulses below the affected injury site indicate normal blood flow to the foot and do not reflect inflammation.

Choice B is wrong because full range of motion at the site of injury is unlikely in the presence of inflammation, which usually causes pain and loss of function.

Choice C is wrong because sanguineous drainage at the site of injury is a sign of bleeding, not inflammation.

Inflammation may cause fluid leakage from blood vessels, but this fluid is usually clear or yellowish, not bloody.

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Correct Answer is A

Explanation

Urinary catheterization is a common cause of health care-associated infections (HAIs), which are infections that patients get while receiving medical treatment in a health care facility. Urinary catheterization involves inserting a tube into the bladder to drain urine, which can introduce bacteria into the urinary tract and cause infections.

Choice B is wrong because malnutrition is not a direct cause of HAIs, although it can weaken the immune system and increase the risk of infections.

Choice C is wrong because multiple caregivers are not a direct cause of HAIs, although they can increase the exposure to different pathogens and cross contamination if they do not follow proper hygiene and infection control practices.

Choice D is wrong because chlorhexidine washes are not a cause of HAIs, but rather a preventive measure to reduce the risk of HAIs by disinfecting the skin and mucous membranes.

A. Place the client on a cardiac monitor. B. Administer a laxative as ordered. C. Place the client on seizure precautions. D. Restrict high potassium foods.

Correct Answer is A

Explanation

This is because hypokalemia (low potassium level in the blood) can cause abnormal heart rhythms (arrhythmia) that can be life-threatening and require urgent medical attention. A cardiac monitor can help detect and treat any arrhythmia that may occur.

Choice B is wrong because administering a laxative can worsen hypokalemia by causing more potassium loss through the digestive tract. Laxative use is one of the possible causes of hypokalemia.

Choice C is wrong because placing the client on seizure precautions is not a priority intervention for hypokalemia. Seizures are not a common symptom of hypokalemia, although muscle weakness and cramps may occur.

Choice D is wrong because restricting high potassium foods is not a priority intervention for hypokalemia. In fact, increasing potassium intake through foods or supplements may be helpful in less serious cases of hypokalemia. However, this should be done according to the doctor’s recommendation and with careful monitoring of blood potassium levels.

Normal blood potassium levels for an adult range from 3.6 to 5.2 millimoles per liter (mmol/L). A very low potassium level (less than 2.5 mmol/L) can be life threatening.

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A nurse is assessing a client who was brought to the emergency department with an ankle injury. Which of the following manifestations should the nurse identify as localized inflammation of the tissues?

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A nurse is assessing a client who was brought to the emergency department with an ankle injury.
Which of the following manifestations should the nurse identify as localized inflammation of the tissues?