A client had a bowel resection 5 days ago. The nurse assesses the client and finds that the client's temperature is 103 degrees F, pulse is 88, respirations are 20, and the blood pressure is 146/72. Urine output has been 160cc for the last 4 hours. The incision is erythemic and warm to touch. The nurse determines that the client's fever is most likely due to what condition?

Wound infection

Urinary tract infection

Respiratory infection

Dehydration

Answer and Explanation

The Correct Answer is A

A.   The combination of fever, tachycardia, decreased urine output, and erythema and warmth at the incision site suggests the possibility of a wound infection.
B.   While a urinary tract infection could cause fever and decreased urine output, the presence of erythema and warmth at the incision site suggests a localized wound infection.
C.   Respiratory infection may cause fever and tachycardia but would not typically present with erythema and warmth at the incision site.
D.   Dehydration may cause decreased urine output but would not typically present with fever and erythema at the incision site.

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Correct Answer is D

Explanation

A. Monocytes are a type of white blood cell involved in immune response and are not typically the most elevated in allergic reactions.
B. Lymphocytes may increase in response to infection or immune stimulation but are not specifically associated with allergic reactions.

C. Neutrophils are the most abundant type of white blood cell and are primarily involved in bacterial infections, not allergic responses.
D. Eosinophils are a type of white blood cell that increases significantly during allergic reactions, making them the most likely to be elevated in response to a severe allergic response like anaphylaxis.

A. A client age 52 who had gall bladder surgery and has osteoarthritis B. A client age 18 who had plastic surgery on nose and is overweight C. A client age 45 with a fractured wrist and in pain D. A client age 78 with Rheumatoid arthritis who had foot surgery and a Foley catheter inserted

Correct Answer is D

Explanation

A. While gall bladder surgery carries a risk of infection, having osteoarthritis does not significantly increase the risk compared to other factors listed.
B. Plastic surgery and being overweight may increase the risk of surgical site infections, but age and comorbidities are more significant factors.

C. A fractured wrist may increase the risk of infection at the fracture site, but it is not as significant a risk factor as advanced age and comorbidities.
D. Advanced age, rheumatoid arthritis, foot surgery, and Foley catheter insertion are all factors that increase the risk of infection, making this client the most vulnerable.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted with a severe allergic response to a bee sting. Which lab would the nurse expect to be the most elevated on the white blood count (WBC) differential?

Correct Answer is D

Explanation

The nurse is caring for several clients on a hospital's surgical unit. Which of the following clients are at greatest risk for developing an infection?

Correct Answer is D

Explanation

The physician orders heparin sodium 6000 units SQ. The pharmacy sends the following vial of heparin. How many mL will the patient receive per dose? (Round to the nearest tenth and label your answer.)

A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include?

The culture from the wound infection shows the organism: Bacterial Staphylococcal Aureus. Which of the following healthcare provider orders would the nurse anticipate?

A nurse is preparing to administer dexamethasone 3 mg PO. Available is dexamethasone 1.5 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number and label your answer).

A nurse is instructing an unlicensed assistive personnel (UAP) on the use of personal protective equipment while caring for clients. Which of the following statements made by the UAP indicates an understanding of standard precaution techniques?

A nurse is planning care for a client who has been placed on airborne precautions. Which of the following in an appropriate nursing precaution?

A nurse is preparing to administer 400 mL of 0.9% sodium chloride IV over 8 hr. The drop factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtts/min? Label your answer.