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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Administering analgesic medications: Analgesic medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or opioids, can help alleviate pain associated with impaired skin integrity by reducing inflammation and blocking pain signals.
B. Performing gentle massage on the affected area: While massage can sometimes provide relief for certain types of pain, it may not be appropriate for all types of impaired skin integrity and could potentially exacerbate the condition or cause further damage.
C. Applying a heating pad to the affected area: Heat therapy may be contraindicated for certain types of impaired skin integrity, as it can increase inflammation and worsen pain. It is not
typically recommended as a primary intervention for managing pain in this context.
D. Using topical antibiotics on the affected area: Topical antibiotics are used to treat or prevent infections but are not primarily indicated for pain management associated with impaired skin
integrity.

A. "All patients are presumed infectious." B. "Isolation is not required for most diseases." C. "Patients with a known infection are placed in isolation only when they are admitted." D. "Patients are not considered infectious until confirmed so by the laboratory."

Correct Answer is A

Explanation

A. "All patients are presumed infectious.": This statement reflects the principle of universal precautions, which assumes that all patients may potentially transmit infectious agents, regardless of their diagnosis or symptoms. It emphasizes the importance of implementing infection prevention practices for every patient encounter to minimize the risk of transmission.
B. "Isolation is not required for most diseases.": While isolation precautions may not be required for all diseases, the statement does not fully capture the concept of universal precautions.
C. "Patients with a known infection are placed in isolation only when they are admitted.": This statement is not accurate as patients with known infections should be placed in isolation as soon as possible to prevent the spread of infection to others.
D. "Patients are not considered infectious until confirmed so by the laboratory.": Waiting for laboratory confirmation before implementing infection control measures could lead to delays in preventing transmission, as patients may be infectious before laboratory results are available.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following interventions can help manage pain associated with impaired skin integrity?

Correct Answer is A

Explanation

The nurse has contributed to a staff education program about the principles for the first tier of standard precautions. Which statement by a nursing student indicates a correct understanding of the teaching?

Correct Answer is A

Explanation

Which of the following assessments should be performed to monitor for impaired tissue integrity?

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Which term should the nurse use to document a raised, fluid-filled lesion smaller than 1 centimeter?

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A nurse in a provider's office is collecting data from a client who has skin lesions. The nurse notes that the lesions are 2.5 cm in size, elevated, solid, and deep. The nurse should document the findings as which of the following skin lesions?