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?
Exudate
Pain
Hyperthermia
Hardening of the tissue
The Correct Answer is C
A. Exudate: Exudate refers to the fluid, such as pus or serum, that is discharged from a wound.
While exudate may be present in infected wounds, it is not a systemic response.
B. Pain: Pain is a localized response to tissue injury and may be present in infected wounds, but it is not a systemic response.
C. Hyperthermia: Hyperthermia, or an elevated body temperature (fever), is a common systemic response to infection, including wound infections. It indicates the body's immune response to the infection.
D. Hardening of the tissue: Hardening of the tissue, known as induration, may occur in infected wounds due to inflammation but is not a specific systemic response.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Amoxicillin: Amoxicillin is a penicillin-type antibiotic effective against susceptible bacteria, but it is not effective against MRSA because MRSA is resistant to penicillin and related antibiotics.
B. Vancomycin hydrochloride: Vancomycin is a glycopeptide antibiotic commonly used to treat MRSA infections due to its effectiveness against MRSA strains. It is considered one of the first-line antibiotics for treating severe MRSA infections.
C. Fluconazole: Fluconazole is an antifungal medication used to treat fungal infections such as candidiasis. It is not effective against bacterial infections like MRSA.
D. Abreva: Abreva is an over-the-counter medication used to treat cold sores caused by the herpes simplex virus. It is not effective against bacterial infections like MRSA.
Correct Answer is A
Explanation
A. Nonadherent dressing: Nonadherent dressings are suitable for small skin tears in older adult clients because they prevent the dressing from sticking to the wound bed, minimizing trauma during dressing changes.
B. Paste: Paste dressings are typically used for wound packing or for managing exuding wounds, not for small skin tears.
C. Moist, sterile gauze: While moist, sterile gauze can be used for wound dressings, it may adhere to the wound bed, causing further trauma during dressing changes.
D. Duoderm: Duoderm is a type of hydrocolloid dressing used for moderate to heavily exuding wounds, not for small skin tears.
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