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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["10"]
Explanation
To answer this question, we need to use the formula:
mL = (dose ordered / dose available) x mL available
Plugging in the values from the question, we get:
mL = (50 mg / 25 mg) x 5 mL
mL = 2 x 5 mL
mL = 10 mL
Therefore, the nurse should administer 10 mL of hydroxyzine oral suspension.
Correct Answer is B
Explanation
A. A client who has a sprained left ankle is typically categorized as a lower priority in triage.
B. A client who has an open traumatic brain injury and agonal breaths should be assigned a red tag and indicates immediate or emergent care; this client requires immediate attention.
C. A client who has sustained a partial amputation of the right leg requires urgent care but may not be as immediately life-threatening as option B.
D. A client who is deceased typically does not receive further medical intervention in a mass casualty situation.
E. While serious, the severity may not necessitate immediate intervention compared to option B.
F. This is typically categorized as a lower priority in triage.
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