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
The correct answer is Choice A.
Choice A rationale: Corn and black beans are naturally gluten-free. They do not contain the storage proteins found in wheat, barley, or rye that trigger the autoimmune response in celiac disease.
Choice B rationale: Barley contains secalin, a type of gluten protein. Ingesting barley causes inflammatory damage to the intestinal villi in patients with celiac disease and must be strictly avoided.
Choice C rationale: Whole wheat contains gliadin, the primary gluten component. This protein triggers an immune-mediated toxic effect on the small intestine, leading to malabsorption and GI distress in affected children.
Choice D rationale: Rye contains gluten proteins that are harmful to those with celiac disease. Additionally, processed meats like bologna often contain hidden gluten as a thickening agent or filler.
Correct Answer is D
Explanation
Choice A rationale
Postterm pregnancy, defined as a gestation extending beyond 42 weeks, is not a contraindication for misoprostol. In fact, it is a common indication for labor induction, as the placenta may begin to deteriorate, increasing the risk of fetal distress and meconium aspiration. Misoprostol, a prostaglandin E1 analog, helps ripen the cervix and stimulate uterine contractions. This pharmacologic action is beneficial in initiating labor in postterm pregnancies.
Choice B rationale
Transverse fetal lie is an obstetrical position where the fetus is lying sideways across the uterus. This position poses a significant risk of complications during vaginal birth, including uterine rupture and umbilical cord prolapse. Therefore, any attempt to induce labor with a medication like misoprostol is contraindicated. Cesarean delivery is typically the preferred method of delivery in cases of persistent transverse lie to ensure a safe delivery for both mother and fetus.
Choice C rationale
Intrauterine growth restriction (IUGR) is a condition where a fetus is smaller than expected for gestational age. It is not a contraindication for misoprostol. Often, IUGR is an indication for labor induction to prevent further fetal compromise. Misoprostol is a commonly used medication for this purpose, as it helps to initiate cervical ripening and uterine contractions, which can lead to a successful vaginal delivery.
Choice D rationale
A history of a cesarean section is a significant contraindication for misoprostol because it substantially increases the risk of uterine rupture. Misoprostol causes potent uterine contractions that can place undue stress on the uterine scar from the previous surgery. The risk of rupture is a life-threatening complication for both the mother and the fetus. Therefore, other methods of labor induction or a planned repeat cesarean section are often considered. *.
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