Which of the following should the nurse recognize as a sign of possible infection in a postoperative client? (Select all that apply.)
Dry crust on the incision line
Adventitious breath sounds
Increased urine output
Decreased level of consciousness
Oral temperature of 38.3° C (101° F)
Correct Answer : B,D,E
A. Dry crust on the incision line may indicate normal healing, not necessarily infection.
B. Adventitious breath sounds can be indicative of pneumonia, a potential infection.
C. Increased urine output is not a sign of infection but may suggest other issues.
D. Decreased level of consciousness suggests a systemic issue, which could include infection affecting the central nervous system.
E. Oral temperature of 38.3° C (101° F) indicates fever which is a common sign of infection.
Nursing Test Bank
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Related Questions
Correct Answer is C
Explanation
A. While blood pressure changes may occur with aging, it is not a direct cause of dehydration.
B. Older adults tend to have a decrease in the percentage of body water, contributing to a higher risk of dehydration.
C. Aging can lead to a decrease in renal function, affecting the body's ability to concentrate urine and conserve water.
D. Saliva production typically decreases with aging and is not a significant factor in dehydration.
Correct Answer is C
Explanation
A. Vomiting is not a specific manifestation of sepsis.
B. Hypertension is not a typical finding in sepsis; hypotension is more common.
C. Altered mental status, such as confusion or lethargy, can be a sign of sepsis- induced organ dysfunction.
D. While an elevated white blood cell (WBC) count is often seen in infection, it alone does not indicate sepsis. The key in sepsis is the body's dysregulated response to infection leading to organ dysfunction.
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