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 B
Explanation
A. A client who has a sprained left ankle is typically categorized as a lower priority in triage.
B. A client who has an open traumatic brain injury and agonal breaths should be assigned a red tag and indicates immediate or emergent care; this client requires immediate attention.
C. A client who has sustained a partial amputation of the right leg requires urgent care but may not be as immediately life-threatening as option B.
D. A client who is deceased typically does not receive further medical intervention in a mass casualty situation.
E. While serious, the severity may not necessitate immediate intervention compared to option B.
F. This is typically categorized as a lower priority in triage.
Correct Answer is A
Explanation
A. Encouraging slow deep breaths involves addressing the client's emotional and psychological well-being, reflecting a holistic approach to pain management.
B. Obtaining blood work is a medical intervention and may not address the holistic aspects of pain management.
C. Requesting a prescription for an analgesic addresses the physical aspect of pain but may not be considered holistic.
D. Checking oxygen saturation is a physiological measure and may not directly address the holistic aspects of pain management.
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