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 {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"B"}}
Explanation
- Place the client in a private room.
- Essential: Placing the client in a private room helps prevent the spread of MRSA to other patients and reduces the risk of transmission.
- Administer intravenous vancomycin.
-
- Essential: Vancomycin is an appropriate antibiotic choice for treating MRSA infections, and administering it intravenously allows for effective delivery of the medication to combat the infection.
- Wear a cover gown when caring for the client.
- Essential: Wearing a cover gown provides an additional barrier of protection against potential contact with the client's infected wound and helps prevent transmission of MRSA to healthcare workers and other patients.
- Restrict fluid intake.
-
- Contraindicated: Restricting fluid intake is not indicated in this scenario. Adequate hydration is essential for supporting the body's immune response and maintaining organ function, especially in the presence of fever and infection.
- Initiate supplemental oxygen.
-
- Nonessential: Supplemental oxygen is not indicated based on the client's oxygen saturation of 96% on room air. Oxygen supplementation is typically reserved for clients who are hypoxic or experiencing respiratory distress, which is not the case here.
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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