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. Popliteal and femoral pulses are not typically used for assessing circulation to the brain.
B. Femoral pulse is not commonly used for assessing brain circulation.
C. The carotid pulse is commonly assessed to evaluate circulation to the brain, especially in emergency situations.
D. Radial pulse is more commonly used to assess peripheral circulation in the arm.

A. Elevate the head of the client’s bed to 45° during meals. B. Instruct the client to tilt their head back while swallowing. C. Turn on the television for the client during meals. D. Provide the client with oral hygiene.

Correct Answer is A

Explanation

A. Elevating the head of the client's bed to 45° during meals helps prevent aspiration by promoting proper swallowing and reducing the risk of food or liquids entering the airway.
B. Instructing the client to tilt their head back while swallowing is not recommended, as it may increase the risk of aspiration.
C. Turning on the television during meals is unrelated to reducing the risk of aspiration pneumonia.
D. Providing the client with oral hygiene is important for overall health but does not specifically address the risk of aspiration pneumonia.

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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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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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