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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

The correct answer is choice A. When conducting a physical assessment of the extremities, the most appropriate assessment would be to assess pulses, capillary refill, strength, edema, skin, and compare with the other extremity. This comprehensive assessment can help to identify potential issues with circulation, strength, and skin integrity, and can also provide a baseline for ongoing assessments. Rebound tenderness in both the arms and legs, skin turgor, and moisture (choice B) are not typically assessed during a physical assessment of the extremities. Assessing the measurements in centimeters of each extremity, pulses, and varicosities (choice C) may be appropriate in certain situations, but it is not a comprehensive assessment of the extremities. Assessing pulses, strength, range of motion, percussion, odor, and edema (choice D) is also not a comprehensive assessment of the extremities and may not provide a complete picture of the client's condition. Therefore, the most appropriate assessment when conducting a physical assessment of the extremities is to assess pulses, capillary refill, strength, edema, skin, and compare with the other extremity.

Correct Answer is ["0.2"]

Explanation

Each mL contains 5,000,000 units. Therefore, to administer 1,000,000 units, we need:

1,000,000 units / 5,000,000 units/mL = 0.2 mL

So, the nurse will give 0.2 mL of reconstituted penicillin G to the client.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When conducting a physical assessment of the extremities, which of the following assessments would be the most correct?

Correct Answer is A

Explanation

The physician orders penicillin G 1,000,000 units IM. The label on the vial of powdered penicillin G reads to reconstitute with 1.6 mL of sterile water to achieve a concentration of 5,000,000 units/mL. How many mL will the nurse give to the client for the ordered dose?

Correct Answer is ["0.2"]

Explanation

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