A nurse is caring for a client with a wound on the lower extremity. What findings would the nurse observe that would indicate a wound infection?

The wound base appears pink to red, with serous drainage, and the client's oral temperature is 99.0°F.

The wound base appears yellow, with serosanguineous drainage, and the client's oral temperature is 100°F.

The wound base appears red, skin is warm to touch with foul odor, and the client's oral temperature is 101.5°F.

The wound base appears yellow, with serous drainage, and the client's oral temperature is 99°F.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. Signs of a wound infection include redness, warmth, and tenderness around the wound, as well as fever, chills, and malaise. The wound base may appear yellow, indicating the presence of pus, and may have a foul odor. Serous drainage is typically clear and does not indicate infection, while serosanguineous drainage may indicate a mild infection or normal healing process. An oral temperature of 101.5°F is elevated and may indicate an infection.

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Correct Answer is B

Explanation

The correct answer is choice B: Dysuria. Dysuria refers to painful or difficult urination. This can be a symptom of a bladder infection, also known as a urinary tract infection (UTI). When documenting a client's condition, it is important to use accurate terminology to communicate effectively with other healthcare professionals. Other terms such as anuria, oliguria, and polyuria refer to different conditions related to urine output and should not be used to describe the symptom of painful urination.

A. The nurse should provide the visitor with details of how the patient is doing but direct the visitor to talk to the family about ways they can help. B. The nurse should state that the family does not need any help and tell the visitor to leave. C. The nurse should tell the visitor that they cannot share any information and ask the visitor to talk to the family directly. D. The nurse should invite the visitor into the home to learn the care techniques required by the client's condition.

Correct Answer is C

Explanation

The correct answer is choice C. The nurse should maintain HIPAA compliance by not sharing any patient information with a non-designated person, even if they identify as a family friend. The nurse should inform the visitor that they cannot share any patient information and suggest that they talk to the patient's family directly if they wish to offer assistance. It is important to protect patient privacy and confidentiality and to only share information with authorized individuals who have a legitimate need to know.

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A nurse is caring for a client with a wound on the lower extremity. What findings would the nurse observe that would indicate a wound infection?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is being treated for bladder infection. The client reports to the nurse that he has been having painful burning with urination. How should the nurse document the client's condition?

Correct Answer is B

Explanation

A home care nurse is caring for a comatose patient who requires total care. A visitor stops by the house identifying as a family friend and inquires about the patient's condition and if there is anything they can do to help the family. How should the nurse respond to maintain HIPAA compliance?

Correct Answer is C

Explanation

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