A client with localized redness, swelling, and tenderness in the upper limb is diagnosed with a skin infection.

The client asks, "Why am I experiencing fever and chills?" How should the nurse respond?

Choice A rationale:

Administering anticoagulant medication is not appropriate for a patient with localized redness, warmth, swelling, pain, and tenderness in the lower limb.

These symptoms suggest a potential inflammatory or infectious process, not a blood clot.

Anticoagulants are used to prevent or treat blood clots, and there is no indication for their use based on the presented symptoms.

Choice B rationale:

Applying cold compresses to the affected area is an appropriate nursing intervention for a patient with localized redness, warmth, swelling, pain, and tenderness.

These symptoms are indicative of inflammation or infection, and cold compresses can help reduce inflammation, relieve pain, and provide comfort to the patient.

Choice C rationale:

Encouraging the patient to ambulate frequently may not be appropriate at this stage.

Ambulation is generally encouraged to prevent complications such as deep vein thrombosis (DVT) in hospitalized patients.

However, in the presence of localized redness, warmth, swelling, pain, and tenderness, it is essential to identify the underlying cause and provide appropriate treatment and rest before promoting ambulation.

Choice D rationale:

Administering acetaminophen for pain relief is a reasonable option, but it addresses only the symptom (pain) and not the underlying cause of the patient's condition.

While pain management is important for patient comfort, it should be combined with interventions that directly address the inflammation or infection responsible for the symptoms.

Therefore, choice B (cold compresses) is a more appropriate initial intervention.

Choice A rationale:

Administering prescribed antibiotics is a crucial nursing intervention in managing cellulitis.

Antibiotics are the primary treatment for bacterial infections, and they are necessary to eradicate the infection.

Choice B rationale:

Teaching the patient proper wound care and hygiene is essential for managing cellulitis.

Proper wound care can help prevent the infection from worsening and promote healing.

Education on wound care is a vital aspect of nursing care for cellulitis.

Choice C rationale:

Advising the patient to apply cold compresses to the affected area is not typically recommended in the management of cellulitis.

Cold compresses may provide some relief for discomfort, but they are not a primary treatment for cellulitis.

Antibiotics and wound care are the mainstay of treatment.

Choice D rationale:

Advising the patient to limit fluid intake is not a standard nursing intervention for managing cellulitis.

In fact, it's important for patients with cellulitis to stay well-hydrated to support their overall health and immune function.

Choice E rationale:

Monitoring for signs of complications, such as fever or worsening symptoms, is a crucial nursing intervention in managing cellulitis.

Cellulitis can lead to serious complications if not promptly identified and treated.

Close monitoring allows for early intervention if complications arise.