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
Crusting over granulated tissue
Petechiae
Urticaria
The Correct Answer is A
A. Edema, which is swelling caused by fluid accumulation in the tissues. Edema is a common sign of inflammation and infection in wounds.
B. Crusting over granulated tissue may indicate normal wound healing and is not necessarily a sign of infection.
C. Petechiae are small red or purple spots on the skin caused by bleeding under the skin. They are usually associated with blood disorders or trauma, not infection.
D. Urticaria (hives) is typically associated with allergic reactions and is not a typical sign of wound infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Emergent (red tag) category includes patients with life-threatening injuries requiring immediate attention, such as a punctured femoral artery.
B. An open fracture may be urgent but not emergent unless associated with severe bleeding or other life-threatening complications.
C. Manifestations of multiple organ failure are severe but may fall into the expectant (black tag) category.
D. Closed fractures with bruising may be urgent but not emergent unless there are associated life-threatening complications.
Correct Answer is D
Explanation
A. Cryosurgery involves freezing the lesion and is typically used for benign lesions.
Malignant melanoma often requires more extensive treatment.
B. Radiation therapy may be used in certain cases, but surgical excision is often the primary treatment for malignant melanoma.
C. Chemotherapy is not the primary treatment for localized malignant melanoma but may be used for advanced cases or metastatic disease.
D. Surgical excision is the primary treatment for localized malignant melanoma, aiming to remove the tumor along with a margin of normal tissue.
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