A nurse is caring for a client with a wound on the lower extremity. What findings would the nurse observe that would indicate a wound infection?
The wound base appears pink to red, with serous drainage, and the client's oral temperature is 99.0°F.
The wound base appears yellow, with serosanguineous drainage, and the client's oral temperature is 100°F.
The wound base appears red, skin is warm to touch with foul odor, and the client's oral temperature is 101.5°F.
The wound base appears yellow, with serous drainage, and the client's oral temperature is 99°F.
The Correct Answer is C
The correct answer is choice C. Signs of a wound infection include redness, warmth, and tenderness around the wound, as well as fever, chills, and malaise. The wound base may appear yellow, indicating the presence of pus, and may have a foul odor. Serous drainage is typically clear and does not indicate infection, while serosanguineous drainage may indicate a mild infection or normal healing process. An oral temperature of 101.5°F is elevated and may indicate an infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A, low-calorie dense foods. Low-calorie dense foods are those that have fewer calories per unit of volume, such as fruits, vegetables, and lean protein sources. These foods can help the client feel full and satisfied while still consuming fewer calories, which is important for weight loss. High trans fat foods (choice B) and high-glycemic index foods (choice C) should be avoided or limited as they can contribute to weight gain and other health problems. Highcalorie dense foods (choice D) should also be avoided or limited as they can provide too many calories without providing enough nutrients.
Correct Answer is D
Explanation
The correct answer is choice D. Identify the five major drug side effects before discharge tomorrow. This is a measurable goal as it has a specific action, which is to identify five major drug side effects, and a specific time frame, which is before discharge tomorrow. The goal is also realistic and achievable within the given time frame. Option A, sitting out of bed in the chair, is not specific enough and lacks a time frame. Option B, verbalizing feelings about surgery at some point, is too vague and lacks a specific action and time frame. Option C, eating low-sodium food, is specific but lacks a time frame and may not be realistic given the client's condition.
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