A patient has been recently diagnosed with an upper respiratory infection. His brother arrives and would like to visit. The patient says he is not feeling strong enough to have visitors. Which symptom would indicate to the nurse that the client is developing a complication?

Dry, occasional cough.

Temperature or Febrile 103 degrees F (39.4 degrees C)

Clear, watery drainage from the nose

Scratchy throat

Answer and Explanation

The Correct Answer is B

A.   Dry, occasional cough: A dry, occasional cough is a common symptom of upper respiratory infections and may not necessarily indicate a complication.
B.   Temperature or Febrile 103 degrees F (39.4 degrees C): A high fever (over 100.4 degrees F or 38 degrees C) is a concerning symptom that may indicate the development of a complication such as pneumonia or a secondary bacterial infection.
C.   Clear, watery drainage from the nose: Clear, watery drainage from the nose is typically associated with viral upper respiratory infections and may not necessarily indicate a complication.
D.   Scratchy throat: A scratchy throat is a common symptom of upper respiratory infections and may not necessarily indicate a complication.

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Correct Answer is B

Explanation

A. Normal white blood cell count: In wound sepsis, the white blood cell count is typically elevated as part of the body's immune response to infection, not normal.
B. Fever and chills: Fever (hyperthermia) and chills are common signs of systemic infection, including wound sepsis. They indicate an inflammatory response and activation of the body's defense mechanisms.
C. Decreased pain at the wound site: Increased pain at the wound site is more commonly associated with wound infection, not decreased pain.
D. Redness and swelling: Redness (erythema) and swelling (edema) are local signs of inflammation and can be present in infected wounds, but they are not specific to wound sepsis and may occur in non-infected wounds as well.

A. Implement neutropenia isolation. B. Disinfect equipment with bleach solution. C. Monitor the client for manifestations of fluid overload. D. Use alcohol hand sanitizer following client care.

Correct Answer is B

Explanation

A. Implement neutropenia isolation: Neutropenia isolation is not applicable for a client with C. diff infection. Neutropenia isolation is used for clients with low neutrophil counts to protect them from exposure to pathogens due to their compromised immune system.
B. Disinfect equipment with bleach solution: Clostridium difficile spores are resistant to many disinfectants, but they can be effectively killed by bleach solutions (sodium hypochlorite).
Disinfecting equipment with bleach solution helps prevent the spread of C. diff infection.
C. Monitor the client for manifestations of fluid overload: Manifestations of fluid overload, such as edema or shortness of breath, are not typically associated with C. diff infection. Monitoring for fluid overload is important in other clinical contexts, such as heart failure.
D. Use alcohol hand sanitizer following client care: Alcohol-based hand sanitizers are not effective against C. diff spores. Hand hygiene should be performed with soap and water, as alcohol-based sanitizers are not effective against C. diff spores.

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A patient has been recently diagnosed with an upper respiratory infection. His brother arrives and would like to visit. The patient says he is not feeling strong enough to have visitors. Which symptom would indicate to the nurse that the client is developing a complication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following is a common sign of wound sepsis?

Correct Answer is B

Explanation

A nurse is caring for a client who has developed a Clostridium difficile (C. diff) infection following antibiotic therapy. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

The nurse works in an office with a dermatologist. What equipment is most important to have readily available when a patient is undergoing skin testing for allergies?

A patient is admitted for treatment for a severe ulcerated pressure injury exhibiting signs of infection. The HCP prescribes open wet dressings to be applied every 6 hours for a period of 30 minutes for one week. For which part of the prescription does the nurse clarify with the physician?

A nurse is preparing to administer vancomycin 250 mg PO. The amount available is vancomycin 125 mg/ capsule. How many capsules should the nurse administer to the client with each dose? (Round to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

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 nurse is caring for a client who has a Clostridium difficile infection. Which of the following cleansing agents should the nurse use for hand hygiene?

A nurse is reinforcing teaching with a client about treatment of Methicillin-Resistant Staphylococcus Aureus (MRSA). Which of the following information should the nurse include in the teaching?

A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to interrupt the transmission of the client's infection?

The nurse is caring for a client with a wound on their leg. During the nurse's assessment, the client explains that he is not feeling well. The nurse knows that a systemic response to a wound infection would be?