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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Dilated and reactive pupils are unrelated to albuterol’s effect. Albuterol, a bronchodilator, relaxes bronchial smooth muscles to improve airflow in emphysema. Pupil changes may indicate neurological or systemic issues but are not a direct indicator of albuterol’s effectiveness in relieving bronchoconstriction and respiratory distress.
Choice B reason: Decreased respiratory rate indicates albuterol’s therapeutic effect in emphysema. Albuterol relaxes constricted airways, improving airflow and reducing the work of breathing. This leads to a slower, more effective respiratory rate, reflecting better oxygenation and relief of bronchospasm, making it the primary sign of therapeutic success.
Choice C reason: Urine output of 50 mL/hr is normal but unrelated to albuterol’s effect. Albuterol targets bronchial smooth muscles to relieve bronchoconstriction in emphysema, improving respiratory function. Urine output reflects renal function, not airway improvement, making it an irrelevant indicator of albuterol’s therapeutic effectiveness in this context.
Choice D reason: A heart rate of 100 beats/minute may occur as a side effect of albuterol’s beta-adrenergic stimulation but is not the primary therapeutic indicator. Albuterol aims to improve airflow and reduce respiratory distress, evidenced by a decreased respiratory rate, not tachycardia, which is a secondary effect.
Correct Answer is ["5"]
Explanation
Step 1 is (2 grams ÷ 10 mL) Result = 0.2 grams per mL
Step 2 is (1 gram ÷ 0.2 grams per mL) Result = 5 mL
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