After a spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which admission assessment finding(s) should the nurse report to the healthcare provider? (Select all that apply.)
Red blood cell count (RBC).
Core body temperature.
Swollen lymph nodes in the groin.
Location of the initial intravenous (IV) site.
White blood cell count (WBC).
Correct Answer : B,C,E
A) Incorrect - Red blood cell count (RBC) is not directly relevant to the assessment of infection and its spread.
B) Correct- Core body temperature can be an indicator of systemic infection and needs to be reported to the healthcare provider for assessment and intervention.
C) Correct- Swollen lymph nodes in the groin suggest local and regional lymphatic involvement, indicating possible spread of infection. This finding needs further assessment and intervention.
D) Incorrect - The location of the initial intravenous (IV) site is not directly relevant to the assessment of infection and its spread.
E) Correct- An elevated white blood cell count (WBC) can indicate an inflammatory response to infection. This finding should be reported to the healthcare provider for further evaluation and treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
These findings suggest potential complications and compromise to the client's circulation and nerve function, which require immediate attention.
Changes in the quality of peripheral pulses indicate alterations in blood flow and may suggest vascular compromise or decreased perfusion to the affected areas. This finding requires immediate intervention to prevent further damage and ensure adequate blood supply to the extremities.
Loss of sensation to the left lower extremity can be indicative of nerve injury or impaired peripheral nerve function. It is important to assess for nerve damage and address it promptly to prevent complications and maximize the client's recovery.
Complaints of increased pain and pressure are concerning because they may indicate the development of compartment syndrome, a serious complication in which pressure within the muscles and tissues builds up to dangerous levels. Prompt intervention is necessary to relieve the pressure and prevent tissue damage.
While sloughing tissue around wound edges and weeping serosanguineous fluid from wounds are important assessment findings in the context of burn care, they do not require immediate intervention compared to the findings mentioned above. These findings should still be addressed and managed appropriately, but they are not considered immediate emergencies.

Correct Answer is B
Explanation
It is important for the nurse to clarify the client's goals for hospitalization, including the client's understanding of the role of radiation therapy in palliative care. The nurse should also assess the client's understanding of the potential benefits and risks of radiation therapy and communicate this information to the healthcare provider.
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