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 C
Explanation
A. Platelets are involved in blood clotting and are not directly related to the body's ability to withstand exposure to pathogens.
B. Hemoglobin carries oxygen in the blood and is not directly related to the body's immune response to pathogens.
C. Neutrophils are a type of white blood cell that plays a key role in the body's immune response to pathogens, including phagocytosis.
D. Erythrocytes, or red blood cells, carry oxygen in the blood and are not directly involved in the body's immune response to pathogens.
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.
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