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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Vomiting is not a specific manifestation of sepsis.
B. Hypertension is not a typical finding in sepsis; hypotension is more common.
C. Altered mental status, such as confusion or lethargy, can be a sign of sepsis- induced organ dysfunction.
D. While an elevated white blood cell (WBC) count is often seen in infection, it alone does not indicate sepsis. The key in sepsis is the body's dysregulated response to infection leading to organ dysfunction.
Correct Answer is B
Explanation
A. Continuous passive motion (CPM) machines are typically used after joint surgeries, not thoracic surgeries.
B. A chest tube is often used postoperatively after a lobectomy to drain excess air, fluid, or blood from the pleural space.
C. A three-way urethral catheter may be used for urinary drainage, but it is not specific to thoracic surgery.
D. Electroencephalography (EEG) monitoring wires are used for monitoring brain activity and are not typically used in the postoperative care of a client following a lobectomy.
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