A nurse is caring for a client who experienced an infection at the insertion site of her intravenous catheter. Which of the following findings should the nurse expect?

The client reports numbness at the site.

Purulent drainage noted from the site

Skin over the site is sloughing

The vein appears cord-like

Answer and Explanation

The Correct Answer is B

A) The client reports numbness at the site: Numbness at the insertion site is not a typical finding of infection. It may indicate nerve damage or another issue but is not specific to infection.

B) Purulent drainage noted from the site: Purulent drainage, characterized by pus-like discharge, is a common sign of infection at the insertion site of an intravenous catheter. It suggests the presence of bacteria and inflammation at the site.

C) Skin over the site is sloughing: Sloughing of the skin may occur with severe tissue damage but is not specific to infection. It could indicate other complications such as tissue necrosis or chemical irritation.

D) The vein appears cord-like: A cord-like appearance of the vein, known as thrombophlebitis, can occur with or without infection. It indicates inflammation and clot formation within the vein, which can be a complication of intravenous catheter insertion, but it does not specifically indicate infection.

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Correct Answer is B

Explanation

B) Placing clean linen that touched the floor in the soiled linen bag: This action demonstrates an understanding of infection control principles because it prevents cross-contamination between clean and soiled linens. Placing clean linens that have come into contact with the floor in the soiled linen bag reduces the risk of spreading pathogens and maintains a clean environment for the client.

A) Placing the soiled linen on the floor before bagging it: This action increases the risk of contamination by exposing the linen to potentially contaminated surfaces. Placing soiled linen on the floor can spread pathogens and is not consistent with infection control practices.

C) Holding the soiled linen against her body while carrying it to the linen bag: This action increases the risk of contamination to the AP's clothing and skin. Contact with soiled linen can transfer pathogens to the caregiver's body, leading to the potential spread of infection.

D) Shaking the soiled linen to remove any toilet paper remnants: This action can aerosolize fecal matter and spread pathogens into the air and onto nearby surfaces. Shaking soiled linen increases the risk of contamination and is not recommended as part of infection control practices.

A. Chronic drainage of fluid through the incision site B. Report by patient that something has given way C. Drainage that is odorous and purulent D. Protrusion of visceral organs through a wound opening

Correct Answer is B

Explanation

A. Chronic drainage of fluid through the incision site:
While chronic drainage of fluid through the incision site can be a sign of wound complications, such as infection or poor wound healing, it is not as specific an indicator of impending wound dehiscence as the patient's report of "something giving way."

B. Report by patient that something has given way:
A patient reporting that something has given way is a significant indicator of potential wound dehiscence. Wound dehiscence refers to the partial or complete separation of the layers of a surgical wound, which can occur due to various factors such as poor wound healing, infection, or increased intra-abdominal pressure. Patients may describe a sensation of "something giving way" or "popping" if the wound starts to separate.

C. Drainage that is odorous and purulent:
Odorous and purulent drainage from an incision site may indicate an infection, which can contribute to wound dehiscence. However, this finding alone may not necessarily indicate immediate wound dehiscence.

D. Protrusion of visceral organs through a wound opening:
Protrusion of visceral organs through a wound opening is a severe complication known as evisceration, which is the most advanced stage of wound dehiscence. While this finding is indicative of a significant wound complication, it typically occurs after the initial separation of wound layers. Therefore, it is not an early sign that would alert the nurse to potential wound dehiscence

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A nurse is caring for a client who experienced an infection at the insertion site of her intravenous catheter. Which of the following findings should the nurse expect?

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