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 A

Explanation

The correct answer is choice A: "The JP drain uses negative suction to drain fluid from the wound." The purpose of the Jackson-Pratt drain is to remove excess fluid or blood from the surgical site. This drain uses a bulb-like container that creates negative pressure or suction, which allows the fluid to be removed from the wound into the container. It is important to maintain negative pressure to ensure that the drain is functioning properly. The nurse should also instruct the client on how to monitor the drainage and how often to empty the container, and to report any changes in the amount, color, or odor of the fluid to the healthcare provider.

A. Air pads wrap around your arms and are connected to a vacuum which improves blood flow. B. These are elastic stockings that apply pressure to the legs and increase the velocity of blood flow. C. SCDs are only worn during amputation to provide support and prevent pooling of blood in the legs. D. The device fills with air that applies intermittent or sequential pressure to the legs to enhance blood flow and venous return.

Correct Answer is D

Explanation

The correct answer is choice D. The nurse would explain to the patient that SCDs work by filling with air and applying intermittent or sequential pressure to the legs to enhance blood flow and venous return. This can help prevent blood clots, such as DVT, from forming in the legs. SCDs are often used for patients who are immobile, such as those who have undergone surgery or who are hospitalized for a medical condition. The device is comfortable to wear and can be adjusted to fit the patient's size and shape. The nurse would also explain the importance of wearing the device as prescribed, and how to properly use and care for it. By using SCDs as directed, the patient can significantly reduce their risk of developing a potentially life-threatening blood clot.

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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

The nurse is teaching a post-operative client about the purpose of their surgical drain. The nurse should include in this teaching which of the following statements regarding the purpose of the Jackson-Pratt (JP) drain?

Correct Answer is A

Explanation

A nurse is implementing interventions to prevent a patient from developing Deep Vein Thrombosis (DVT) in the legs by applying a pneumatic or sequential compression device (SCD's). Which explanation would the nurse give the patient in regards to how this device works?

Correct Answer is D

Explanation

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