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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. A client who has a sprained left ankle is typically categorized as a lower priority in triage.
B. A client who has an open traumatic brain injury and agonal breaths should be assigned a red tag and indicates immediate or emergent care; this client requires immediate attention.
C. A client who has sustained a partial amputation of the right leg requires urgent care but may not be as immediately life-threatening as option B.
D. A client who is deceased typically does not receive further medical intervention in a mass casualty situation.
E. While serious, the severity may not necessitate immediate intervention compared to option B.
F. This is typically categorized as a lower priority in triage.

A. Instruct client to use an incentive spirometer every 4 hr. B. Place the client in a room with negative-pressure airflow. C. Serve cooked fruit with meals. D. Report temperatures greater than 39.5 C (102.3 F lasting more than 4 hr.)

Correct Answer is D

Explanation

A. The use of an incentive spirometer is more relevant for preventing respiratory complications, not related to the client's low WBC count.
B. Negative-pressure airflow rooms are typically used for clients with airborne infections, not those with low WBC counts.
C. Cooked fruits may be advisable to reduce the risk of bacterial contamination in immunosuppressed clients, but it does not directly address the low WBC count.
D. Reporting temperatures greater than 39.5°C (102.3°F) lasting more than 4 hours is crucial as it may indicate an infection, and prompt intervention is needed in immunosuppressed clients.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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