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 C

Explanation

A. Seeking a second opinion suggests the client may be exploring different treatment options, indicating some level of hope for improvement.
B. Expressing plans to stop treatment may indicate frustration or dissatisfaction but does not necessarily reflect acceptance of the prognosis.
C. Expressing a desire for symptom relief (in this case, discomfort) is indicative of an understanding and acceptance of palliative care.
D. Stating that the treatment is making the client stronger every day may reflect a positive attitude but does not necessarily indicate acceptance of the prognosis.

A. Elevate the head of the client’s bed to 45° during meals. B. Instruct the client to tilt their head back while swallowing. C. Turn on the television for the client during meals. D. Provide the client with oral hygiene.

Correct Answer is A

Explanation

A. Elevating the head of the client's bed to 45° during meals helps prevent aspiration by promoting proper swallowing and reducing the risk of food or liquids entering the airway.
B. Instructing the client to tilt their head back while swallowing is not recommended, as it may increase the risk of aspiration.
C. Turning on the television during meals is unrelated to reducing the risk of aspiration pneumonia.
D. Providing the client with oral hygiene is important for overall health but does not specifically address the risk of aspiration pneumonia.

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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 caring for a client who has cancer and is receiving palliative care. Which of the following statements should the nurse identify as an indication that the client understands and accepts his prognosis?

Correct Answer is C

Explanation

A nurse is caring for a client who has dementia. Which of the following actions should the nurse take to reduce the client’s risk of aspiration pneumonia?

Correct Answer is A

Explanation

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