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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Staphylococcus aureus is often susceptible to antibiotics, so supportive interventions without antibiotics would not be appropriate.
B. The most appropriate action for treating an infection caused by Staphylococcus aureus would be to administer an antibiotic to which the organism is sensitive.
C. While wound irrigation may be part of the treatment plan for wound infections, using a hypotonic solution to wash out elevated electrolytes is not specifically indicated for Staphylococcus aureus infections.
D. Applying cold to the wound site would not be the primary treatment for a wound infection caused by Staphylococcus aureus. Antibiotic therapy is necessary to address the bacterial infection.
Correct Answer is ["B","D","E","F","H","J"]
Explanation
A. While encouraging fluid intake is generally beneficial, this action alone may not adequately address the client's respiratory distress.
B. Obtaining the client's vital signs and noting changes from previous readings is essential for assessing the client's condition and response to interventions.
C. Administering antitussive medication may not be appropriate as the client is able to expectorate secretions, and suppressing the cough may hinder clearance of secretions.
D. Positioning the client in a high-Fowler position helps improve lung expansion, aiding in respiratory effort.
E. Increasing the supplemental oxygen flow can help alleviate respiratory distress by improving oxygenation.
F. Calling the respiratory therapist for a nebulizer treatment is appropriate, especially since the client reported previous relief with this intervention.
G. Increasing IV fluids may not directly address the client's respiratory distress and should be based on fluid status and other clinical indications.
H. Documenting findings and actions taken ensures proper communication and continuity of care.
I. Contacting the Rapid Response Team may not be necessary as the client is alert and oriented and not in immediate distress.
J. Listening to the client's breath sounds allows the nurse to compare with previous findings and evaluate respiratory status.
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