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 C
Explanation
A. Encouraging the client to talk about his feelings is important, but understanding the client's current perception of his body image comes first to guide appropriate interventions.
B. Discussing coping strategies is relevant, but understanding the client's current perception helps tailor coping strategies to his specific concerns.
C. Determining the client's perception of his body image is the first step to assess the extent of the issue and plan interventions accordingly.
D. Assisting the client to acknowledge a distorted body image may be necessary, but understanding the client's current perception precedes interventions.
Correct Answer is A
Explanation
A. Lactated Ringer’s is the preferred fluid for fluid resuscitation in the first 24 hours after a burn injury as it helps replace lost fluids and electrolytes.
B. Dextrose 5% in water is not the primary fluid for burn resuscitation.
C. 0.9% sodium chloride may be used, but Lactated Ringer’s is often preferred.
D. Dextrose 5% in 0.9% sodium chloride is not the primary fluid for burn resuscitation.
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