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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Hypovolemic shock typically results in low blood pressure (BP) and a compensatory increase in pulse rate to maintain cardiac output.
B. Low BP and high pulse rate are characteristic findings in hypovolemic shock, reflecting decreased circulating blood volume.
C. High BP is not a typical finding in hypovolemic shock; the BP tends to decrease due to reduced blood volume.
D. Low BP and low pulse rate are not consistent with the compensatory response seen in hypovolemic shock.
Correct Answer is ["A","D"]
Explanation
A. Using clean technique helps prevent contamination during catheter dressing changes.
B. Changing the catheter dressing every 2 days may not be necessary, and frequency should be based on the facility's policy and the client's condition.
C. Povidone-iodine is not the recommended antiseptic for cleaning the access port.
Alcohol or chlorhexidine is typically recommended.
D. Proper hand hygiene is crucial to prevent introducing pathogens during catheter care.
E. Using friction when cleaning the access port is not a recommended practice and may cause damage. Cleaning should be done gently to avoid compromising the integrity of the site.
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