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A nurse is completing a head-to-toe assessment on a client who is 3 days post-operative from a right mastectomy. Which of the following should the nurse recognize as a sign of possible infection? Select all that apply.

Client reports no pain

Oral temperature of 98.9 degrees F

Decreased level of consciousness

WBCs are 15,000

Scab forming on incision line

Crackles in bilateral lung bases

Incision is red and warm to touch

Answer and Explanation

Correct Answer : C,D,F,G

A. The absence of pain does not necessarily indicate the absence of infection.

B.   An oral temperature of 98.9 degrees F is within the normal range and does not indicate infection.
C.   Decreased level of consciousness can be a sign of systemic infection, especially if accompanied by other symptoms.
D.   An elevated white blood cell count (WBC) is indicative of an inflammatory response, which can occur in infection.
E.   A scab forming on the incision line is a normal part of wound healing and does not necessarily indicate infection.
F.   Crackles in bilateral lung bases may indicate a possible infection.

G. Redness and warmth at the incision site are signs of inflammation and can indicate infection.

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Correct Answer is D

Explanation

A. While a repeat titer could be considered, if the initial result is negative, administration of the rubella vaccine is typically the next step.
B. Administration of immune globulin is not indicated in this scenario.

C. A negative rubella titer indicates lack of immunity, so further action is needed to protect the individual.
D. Administration of the rubella vaccine is indicated for individuals with a negative rubella titer to provide protection against rubella infection.

A. Encourage the client to cough and deep breathe. B. Turn client every 2 hours. C. Keep skin clean and dry. D. Apply lotion to clean skin. E. Help the client void.

Correct Answer is ["A","B","C","D","E"]

Explanation

A. Encouraging the client to cough and deep breathe helps to maintain clear airways and prevent respiratory infections.
B. Turning the client every 2 hours is important for preventing pressure ulcers and maintaining skin integrity.
C. Keeping the skin clean and dry helps to prevent skin breakdown and infections, serving as a barrier against pathogens.
D. Applying lotion to clean skin may keep the skin moisturized hence preventing skin breakdown.

E. Urinary incontinence is associated with skin breakdown hence the development of bedsores. Therefore, assisting the client with voiding is important for maintaining urinary function and skin integrity.

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A nurse is completing a head-to-toe assessment on a client who is 3 days post-operative from a right mastectomy. Which of the following should the nurse recognize as a sign of possible infection? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A newly hired nurse is completing their health evaluation and physical for their new employment. The laboratory technician draws a titer for rubella. The laboratory results are negative. What would be the next action?

Correct Answer is D

Explanation

The nurse is caring for a 67-year old client, who is on bedrest. Which of the following nursing actions should the nurse include in the plan of care to help maintain the body's first line of defense? Select all that apply.

Correct Answer is ["A","B","C","D","E"]

Explanation

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