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 C

Explanation

A. Allergic responses typically involve an increase in eosinophils rather than lymphocytes.
B. While an inflammatory response may involve an increase in lymphocytes, the presentation of clear nasal drainage and cough with bilateral rales suggests a respiratory infection rather than a generalized inflammatory process.
C. Elevated lymphocytes are often indicative of a viral infection, as the body mounts an immune response to fight off the viral invader.
D. Bacterial infections typically involve an increase in neutrophils rather than lymphocytes, although lymphocytosis may occur in some bacterial infections as part of the immune response.

A. obtain a repeat titer B. administration of immune globulin C. nothing, the nurse has protection D. administration of the rubella vaccine

Correct Answer is D

Explanation

A. While a repeat titer could be considered, if the initial result is negative, administration of the rubella vaccine is typically the next step.
B. Administration of immune globulin is not indicated in this scenario.

C. A negative rubella titer indicates lack of immunity, so further action is needed to protect the individual.
D. Administration of the rubella vaccine is indicated for individuals with a negative rubella titer to provide protection against rubella infection.

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Naxlex Comprehensive Predictor Exams

A client is admitted with cough, congestion, bilateral rales, and clear nasal drainage. In reviewing the differential WBC the nurse notes the lymphocytes are elevated. How should the nurse interpret the elevated lymphocytes?

Correct Answer is C

Explanation

A newly hired nurse is completing their health evaluation and physical for their new employment. The laboratory technician draws a titer for rubella. The laboratory results are negative. What would be the next action?

Correct Answer is D

Explanation

A nurse is providing health teaching to a client about ways a communicable disease is transmitted by contact. Select all that apply.

A nurse is caring for a client who has a wound infection. Wound cultures identify the infecting organism as vancomycin-resistant enterococci (VRE). Which type of precautions should the health care team initiate?

A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection?

The nurse is caring for a client with a large abdominal wound. The nurse knows to cleanse the wound from the inner to outer area. What is the rationale for cleaning the wound in this manner?

A client asks the nurse what is meant by the term benign. Which response by the nurse is best?

A baby is born temporarily immune to the diseases to which the mother is immune. The nurse would explain this to the mother as being which of the following types of immunity?