A nurse is replacing the dressing for a client who is postoperative following thoracic surgery.
When assessing the surgical wound, which of the following findings should the nurse identify as an indication of infection?
Crusting along the incision line.
Temperature of 37.2° C (99° F).
Pink coloration of the incision line.
Swelling extending 3.8 cm (1.5 in) from the incision.
The Correct Answer is D
Choice A rationale
Crusting along the incision line is the result of dried serous fluid and blood, which is a normal part of the wound healing process during the inflammatory phase. This finding alone is not indicative of a surgical site infection, which is characterized by other signs.
Choice B rationale
A temperature of $37.2^\circ C$ ($99^\circ F$) is within the normal range for body temperature ($36.1^\circ C$ to $37.2^\circ C$ or $97^\circ F$ to $99^\circ F$). An elevated temperature, specifically a fever, is a systemic sign of infection. A low-grade fever might be a subtle sign, but this temperature is not high enough.
Choice C rationale
Pink coloration of the incision line is a normal finding in the early stages of wound healing, representing angiogenesis, the formation of new blood vessels. This process is crucial for tissue repair and does not indicate a surgical site infection, which is typically characterized by erythema and warmth.
Choice D rationale
Swelling, or edema, is a classic sign of inflammation and infection. While some minor swelling is normal, swelling that extends significantly beyond the wound margins, such as 3.8 cm (1.5 in), indicates a heightened inflammatory response potentially due to bacterial proliferation and infection. *.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Informed consent is a dynamic and ongoing process, not a one-time event. A client has the autonomous right to refuse a procedure at any point, even after having previously signed a consent form. This right is based on the principle of client autonomy, which states that competent individuals have the right to make decisions about their own healthcare, including the right to withdraw consent at any time. The signed form simply documents that the discussion occurred; it does not nullify the client's right to change their mind.
Choice B rationale
The ability to write is not a prerequisite for providing informed consent. A client who is unable to write can still provide verbal consent, and this is typically documented by a witness. The key components of informed consent are the client's understanding of the procedure and their voluntary agreement. As long as the client can comprehend the information and communicate their decision, they are considered capable of providing consent. A mark or a signature from a witnessed verbal consent can be used to formalize the documentation process.
Choice C rationale
A client who is blind is fully capable of providing informed consent as long as they can understand the information being presented. The nurse or healthcare provider must ensure that the information is communicated in a manner the client can comprehend, which may include reading the consent form aloud and answering any questions. The visual impairment does not compromise the client's cognitive ability to make decisions about their own healthcare, and therefore, a guardian is not required for this reason.
Choice D rationale
While a nurse can and often does clarify information, the primary responsibility for explaining surgical risks and benefits to a client lies with the surgeon or the healthcare provider performing the procedure. The physician must provide a comprehensive explanation of the procedure, including all potential risks, benefits, and alternatives, to ensure the client is fully informed. The nurse's role is to act as a witness to the signature and to ensure the client has had their questions answered, and to notify the provider if they have new questions or concerns. *.
Correct Answer is ["18.25"]
Explanation
Step 1: convert the height from cm to meters. 175 cm ÷ 100 = 1.75 m.
Step 2: calculate BMI using the formula $BMI = weight (kg) ÷ height (m)^2$. BMI = 55.9 kg ÷ (1.75 m × 1.75 m).
Step 3: calculate the denominator. 1.75 m × 1.75 m = 3.0625 m$^2$.
Step 4: divide the weight by the denominator. 55.9 kg ÷ 3.0625 m$^2$ = 18.25. The client's BMI is 18.3.
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