A nurse is changing the dressing on a client’s wound. The nurse should recognize that which of the following findings is an indication of a wound infection?

Edema

Crusting over granulated tissue

Petechiae

Urticaria

Answer and Explanation

The Correct Answer is A

A.   Edema, which is swelling caused by fluid accumulation in the tissues. Edema is a common sign of inflammation and infection in wounds.
B.   Crusting over granulated tissue may indicate normal wound healing and is not necessarily a sign of infection.
C.   Petechiae are small red or purple spots on the skin caused by bleeding under the skin. They are usually associated with blood disorders or trauma, not infection.
D.   Urticaria (hives) is typically associated with allergic reactions and is not a typical sign of wound infection.

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Correct Answer is D

Explanation

A. Creatine kinase is an enzyme associated with muscle damage, not an indicator of infection.
B. Hemoglobin (Hgb) measures the amount of oxygen-carrying pigment in the blood and is not specific to infection.
C. Platelet count reflects the number of platelets in the blood and is not a direct indicator of infection.
D. An elevated white blood cell (WBC) count is indicative of an immune system response to infection.

A. Instruct the client to stay in the bathtub no longer than 20 min. B. Fill the bathtub with water at 48 C (118.4° F). C. Use bath oil in the client’s bathtub D. Provide the client with non-slip bath strips in the bathtub.

Correct Answer is D

Explanation

A. The duration of time in the bathtub should be based on the client's tolerance but should not exceed 20 minutes.
B. Water temperature should be warm but not excessively hot to avoid burns or discomfort.
C. Bath oils can make the bathtub slippery and increase the risk of falls. They should be avoided.
D. Providing non-slip bath strips enhances safety and helps prevent the client from slipping in the bathtub.

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A nurse is changing the dressing on a client’s wound. The nurse should recognize that which of the following findings is an indication of a wound infection?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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