A nurse is collecting data from four clients who have wounds. The nurse should recognize that which of the following clients has a manifestation of a wound infection?

A client who has swelling and tenderness around the wound

A client who has brown crusting over the wound

A client who has serosanguineous drainage from the wound

A client who has urticaria and itching around the wound

Answer and Explanation

The Correct Answer is A

A.   Swelling and tenderness around the wound are common signs of infection, indicating an inflammatory response to the presence of bacteria.
B.   Brown crusting over the wound may suggest the presence of a scab or dried exudate, which is a normal part of the healing process and not necessarily indicative of infection.
C.   Serosanguineous drainage is a type of wound drainage that is typically not a sign of infection but rather a mix of clear and blood-tinged fluid.
D.   Urticaria and itching around the wound suggest an allergic reaction rather than a wound infection.

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Correct Answer is C

Explanation

A. Acute pain is more likely to increase respiratory rate, not decrease it.
B. Acute pain does not typically cause hypoglycemia.
C. Acute pain is often associated with an increase in blood pressure (hypertension).
D. Acute pain tends to increase heart rate (tachycardia), not decrease it.

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 collecting data from four clients who have wounds. The nurse should recognize that which of the following clients has a manifestation of a wound infection?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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