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Which of the following should the nurse recognize as a sign of possible infection in a postoperative client? (Select all that apply.)

A.

Dry crust on the incision line

B.

Adventitious breath sounds

C.

Increased urine output

D.

Decreased level of consciousness

E.

Oral temperature of 38.3° C (101° F)

Answer and Explanation

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.
 


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Related Questions

Correct Answer is A

Explanation

A. Standards of care published by reputable organizations, such as the Oncology Nursing Society, provide evidence-based guidelines and best practices.
B. While the experience of a nurse in a chemotherapy clinic is valuable, it may not represent standardized, evidence-based practices.
C. A qualitative study may provide insights into clients' perspectives but may not necessarily offer specific interventions for oral care.
D. Published textbooks can be valuable resources, but standards of care from professional organizations are generally more up-to-date and evidence-based.

Correct Answer is A

Explanation

A. Calcium carbonate can cause kidney stones, which may result in flank pain.
B. Tinnitus is not a common adverse effect of calcium carbonate.
C. Calcium carbonate is not known to cause bradycardia.
D. Urinary retention is not a common adverse effect of calcium carbonate.

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