A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching?

A. Temperature: A temperature of 38.3°C (101°F) indicates fever, which can signal a systemic inflammatory response or infection. In a client with a pressure injury that has developed purulent drainage and foul odor, fever raises concern for wound infection or possible systemic spread. This finding requires prompt provider notification for potential antibiotic therapy and further evaluation.

B. WBC count: A WBC count of 12,000/mm³ is elevated above the normal range and suggests an inflammatory or infectious process. In the context of a worsening pressure injury with purulent drainage, leukocytosis supports the possibility of an active infection. Reporting this finding allows the provider to consider diagnostic tests and treatment such as wound cultures or antimicrobial therapy.

C. Prealbumin level: The prealbumin level of 12 mg/dL is below the normal range, indicating poor nutritional status. Adequate protein and caloric intake are essential for wound healing and tissue regeneration. Low prealbumin can impair the healing of pressure injuries and may require nutritional intervention, supplementation, or referral to a dietitian.

D. Hemoglobin level: The hemoglobin level of 13 g/dL falls within the normal reference range for adults. Adequate hemoglobin supports oxygen delivery to tissues, which is important for wound healing. Because this value is within normal limits, it does not require reporting as an abnormal finding.

E. Blood pressure: The blood pressure reading of 128/64 mm Hg is within an acceptable range and does not indicate hemodynamic instability. There are no signs of hypotension or hypertension that would compromise tissue perfusion or indicate acute deterioration. Therefore, this value does not require immediate reporting.

F. Pain level: The client’s pain has increased from 2/10 on Day 1 to 6/10 on Day 4, indicating worsening discomfort. Increasing pain in a pressure injury may signal infection, tissue deterioration, or inflammation. This change in pain level should be reported because it represents a significant clinical change requiring reassessment of wound management and pain control.

G. Odor of wound: A foul odor from a pressure injury is commonly associated with bacterial infection or necrotic tissue. When combined with purulent drainage and yellow wound tissue, it strongly suggests wound deterioration and possible infection. This finding should be reported promptly for evaluation and potential treatment adjustments.

H. Bowel sounds: Active bowel sounds in all four quadrants indicate normal gastrointestinal motility. This is a normal assessment finding and is unrelated to the client’s pressure injury status. Because it does not represent a complication or abnormal change, it does not need to be reported to the provider.

A. Ensure sterilization of nondisposable items with ethylene oxide: Ethylene oxide is a sterilizing agent used for heat-sensitive equipment, but it does not remove latex proteins from items that contain latex. If equipment contains latex, sterilization alone will not eliminate the allergenic proteins capable of triggering a reaction.

B. Wrap monitoring cords with stockinette and tape them in place: Clients with latex allergy must be protected from direct contact with items that may contain latex components. Covering monitoring cords with stockinette or similar barriers prevents skin contact with potential latex-containing materials in the operating environment. This reduces the risk of contact reactions.

C. Cleanse latex ports on IV tubing with chlorhexidine before injecting medication: Disinfecting an injection port with chlorhexidine removes microorganisms but does not neutralize latex proteins. For clients with latex allergy, latex-free IV equipment should be used rather than attempting to disinfect latex components.

D. Wear hypoallergenic latex gloves that contain powder: Hypoallergenic latex gloves still contain latex proteins that can trigger allergic reactions. Powdered gloves further increase the risk because the powder can carry airborne latex particles that are easily inhaled or deposited on surfaces. In a latex-allergic environment, non-latex gloves such as nitrile or vinyl are required.