A nurse is caring for a client with a postoperative wound infection. Which finding indicates the infection is worsening and requires immediate intervention?

Localized redness around the wound

Serous drainage from the wound

Fever of 101.5°F and increased heart rate

Mild tenderness at the wound site

Answer and Explanation

The Correct Answer is C

Choice A reason: Localized redness is an expected sign of early wound infection due to localized inflammation but does not necessarily indicate worsening. It reflects immune response to infection, manageable with antibiotics, but systemic signs like fever and tachycardia suggest severe infection, requiring more urgent intervention.

Choice B reason: Serous drainage is normal in early wound healing or mild infection but does not indicate worsening. Purulent or foul-smelling drainage would suggest progression, but serous drainage is less concerning, making it a lower priority than systemic signs like fever and tachycardia.

Choice C reason: Fever of 101.5°F and increased heart rate indicate a worsening wound infection, suggesting systemic spread (sepsis). These signs reflect the body’s response to significant bacterial proliferation, risking septic shock, requiring immediate intervention like antibiotics or surgical debridement to prevent life-threatening complications.

Choice D reason: Mild tenderness is expected in an infected wound due to localized inflammation but does not indicate worsening. Systemic signs like fever and tachycardia suggest severe infection or sepsis, making tenderness a less urgent finding requiring monitoring rather than immediate intervention.

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Correct Answer is B

Explanation

Choice A reason: Wheezes are high-pitched, musical sounds caused by narrowed airways, common in asthma or COPD exacerbations. They do not clear with coughing and are not moist or rumbling, making this an incorrect description for the lung sounds heard, which improve after coughing in this COPD client.

Choice B reason: Rhonchi are low-pitched, moist, rumbling sounds caused by secretions in larger airways, often in COPD. They improve with coughing as secretions are mobilized, matching the description provided. This makes rhonchi the accurate term for documenting these lung sounds, reflecting secretion accumulation in COPD.

Choice C reason: Crackles are fine or coarse popping sounds caused by fluid in smaller airways or alveoli, often in pneumonia or heart failure. They do not clear with coughing and are not rumbling, making crackles an incorrect choice for the moist, rumbling sounds that improve after coughing.

Choice D reason: Pleural friction rub is a grating sound caused by inflamed pleural surfaces, often in pleurisy. It is not moist or rumbling and does not improve with coughing, making it an inappropriate description for the lung sounds heard in this client with COPD, which are secretion-related.

A. I will make sure I have a good breakfast before my surgery. B. I will be given an antibiotic prior to surgery to prevent infection. C. I will refrain from smoking 8 hours before surgery. D. I will shower with Hibiclens the morning of surgery.

Correct Answer is A

Explanation

Choice A reason: Eating breakfast before surgery indicates a need for further teaching, as fasting (nothing by mouth) after midnight prevents aspiration during anesthesia. Food intake increases gastric contents, risking pulmonary complications, making this a critical misunderstanding requiring correction to ensure safe surgical preparation.

Choice B reason: Receiving an antibiotic preoperatively is standard to prevent surgical site infections, especially in high-risk procedures. This statement reflects correct understanding, as prophylactic antibiotics reduce bacterial load, minimizing postoperative infection risk, indicating no need for further teaching on this point.

Choice C reason: Refraining from smoking 8 hours before surgery is appropriate, as smoking increases airway reactivity and secretions, risking respiratory complications. This shows understanding, though longer cessation is ideal, making further teaching unnecessary for this specific preoperative instruction.

Choice D reason: Showering with Hibiclens (chlorhexidine) the morning of surgery is correct, as it reduces skin bacterial load, lowering infection risk. This statement reflects proper understanding of preoperative skin preparation, indicating no need for further teaching on this aspect of surgical preparation.

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A nurse is caring for a client with a postoperative wound infection. Which finding indicates the infection is worsening and requires immediate intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) and auscultates moist, rumbling sounds that improve after the client coughs. How will the nurse document the lung sounds?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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