A nurse is changing the dressing on a client's wound. The nurse should recognize that which of the following findings is an indication of a wound infection?
Edema
Petechiae
Urticaria
Crusting over granulated tissue
The Correct Answer is A
The correct answer is: a. Edema.
Choice A: Edema
Edema is swelling caused by excess fluid trapped in the body’s tissues. It is a common sign of inflammation and infection. When a wound becomes infected, the body’s immune response can cause increased fluid accumulation in the affected area, leading to noticeable swelling. This swelling is often accompanied by redness, warmth, and pain, which are classic signs of infection.
Choice B: Petechiae
Petechiae are small, red or purple spots caused by bleeding into the skin. They are not typically associated with wound infections but rather with conditions that cause bleeding or clotting disorders. Petechiae do not indicate an infection but rather a different underlying issue that may require further investigation.
Choice C: Urticaria
Urticaria, also known as hives, is a skin reaction that causes itchy welts. It is usually a result of an allergic reaction and is not a sign of wound infection. Urticaria is characterized by raised, red, itchy bumps on the skin and does not typically occur in response to an infected wound.
Choice D: Crusting over granulated tissue
Crusting over granulated tissue is a normal part of the wound healing process. Granulation tissue forms as the wound heals, and a crust or scab may develop over it to protect the new tissue underneath. This is not an indication of infection but rather a sign that the wound is progressing through the healing stages.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Protective precautions are used to shield immunocompromised patients from infections, not typically for patients with meningococcal pneumonia.
Choice B reason: Contact precautions are used for infections that are spread by direct contact with the patient or the patient's environment. Meningococcal pneumonia is not primarily spread this way.
Choice C reason: Airborne precautions are for diseases that are spread through the air over long distances, such as tuberculosis. Meningococcal pneumonia is not spread in this manner.
Choice D reason: Droplet precautions are recommended for meningococcal pneumonia. This infection can be spread through droplets from the respiratory tract when the infected person coughs or sneezes. Therefore, droplet precautions, including the use of masks, are necessary to prevent the spread of this infection.
Correct Answer is A
Explanation
The correct answer is: a. Edema.
Choice A: Edema
Edema is swelling caused by excess fluid trapped in the body’s tissues. It is a common sign of inflammation and infection. When a wound becomes infected, the body’s immune response can cause increased fluid accumulation in the affected area, leading to noticeable swelling. This swelling is often accompanied by redness, warmth, and pain, which are classic signs of infection.
Choice B: Petechiae
Petechiae are small, red or purple spots caused by bleeding into the skin. They are not typically associated with wound infections but rather with conditions that cause bleeding or clotting disorders. Petechiae do not indicate an infection but rather a different underlying issue that may require further investigation.
Choice C: Urticaria
Urticaria, also known as hives, is a skin reaction that causes itchy welts. It is usually a result of an allergic reaction and is not a sign of wound infection. Urticaria is characterized by raised, red, itchy bumps on the skin and does not typically occur in response to an infected wound.
Choice D: Crusting over granulated tissue
Crusting over granulated tissue is a normal part of the wound healing process. Granulation tissue forms as the wound heals, and a crust or scab may develop over it to protect the new tissue underneath. This is not an indication of infection but rather a sign that the wound is progressing through the healing stages.
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