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)

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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Correct Answer is D

Explanation

A. The duration of time in the bathtub should be based on the client's tolerance but should not exceed 20 minutes.
B. Water temperature should be warm but not excessively hot to avoid burns or discomfort.
C. Bath oils can make the bathtub slippery and increase the risk of falls. They should be avoided.
D. Providing non-slip bath strips enhances safety and helps prevent the client from slipping in the bathtub.

A. Allow the client to choose free-time activities B. Post a written schedule of daily activities. C. Provide a consistent daily routine. D. Use an overhead loudspeaker to announce events

Correct Answer is C

Explanation

Individuals with dementia often benefit from routine, but too many choices can be overwhelming.
B: While a written schedule can be helpful, a consistent routine is generally more beneficial for clients with dementia.
C: Providing a consistent daily routine helps decrease anxiety and confusion for clients with dementia.
D: Overhead loudspeakers may cause agitation and confusion in clients with dementia.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting a client who had a lower extremity amputation with a bath. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is contributing to the plan of care for a client who has dementia. Which of the following actions should the nurse include in the plan of care?

Correct Answer is C

Explanation

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