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 A

Explanation

A. Emergent (red tag) category includes patients with life-threatening injuries requiring immediate attention, such as a punctured femoral artery.
B. An open fracture may be urgent but not emergent unless associated with severe bleeding or other life-threatening complications.
C. Manifestations of multiple organ failure are severe but may fall into the expectant (black tag) category.
D. Closed fractures with bruising may be urgent but not emergent unless there are associated life-threatening complications.

A. Encourage the client to take slow deep breaths. B. Obtain blood work from the client. C. Request a prescription for an analgesic for the client. D. Check the clients oxygen saturation level

Correct Answer is A

Explanation

A. Encouraging slow deep breaths involves addressing the client's emotional and psychological well-being, reflecting a holistic approach to pain management.
B. Obtaining blood work is a medical intervention and may not address the holistic aspects of pain management.
C. Requesting a prescription for an analgesic addresses the physical aspect of pain but may not be considered holistic.
D. Checking oxygen saturation is a physiological measure and may not directly address the holistic aspects of pain management.

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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

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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