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 A
Explanation
A. Critical pathway provides a specific, timeline-based plan of care with expected outcomes and interventions, including activity levels.
B. Standards of care are important but may not offer specific guidance for the individual client's daily activity level.
C. Guidelines may provide general recommendations but may lack specificity.
D. This is general information source but not as specific or current as the institution's critical pathway.
Correct Answer is A
Explanation
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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