A nurse is collecting data from a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply.)
Bradycardia
An increase in platelets
An increase in RBCs
An increase in neutrophils
Localized edema
Correct Answer : D,E
A. Bradycardia is not typically a sign of infection. Infections usually lead to tachycardia (increased heart rate) rather than bradycardia.
B. An increase in platelets An increase in the platelet count can reflect malignancies, not infection.
C. An increase in RBCs is not typically associated with infection. Infection generally does not increase the number of red blood cells but may lead to changes in white blood cell counts.
D. An increase in neutrophils is a common response to bacterial infection. Neutrophils are white blood cells that increase in number to fight off infections.
E. Localized edema is often present in areas of infection due to inflammation and fluid accumulation in response to infection and tissue damage.
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Related Questions
Correct Answer is B
Explanation
A. Turning the client onto her side could worsen the situation by increasing pressure on the abdominal area and potentially further damaging the eviscerated tissue. The priority is to manage the wound.
B. The correct intervention is to cover the wound with a moist sterile dressing to prevent further contamination and to protect the exposed organs. The nurse should also notify the surgical team immediately.
C. Applying an abdominal binder could put pressure on the wound and exacerbate the evisceration. It is not appropriate for the immediate care of an eviscerated wound.
D. Evisceration is a medical emergency and should never be considered an expected occurrence. The nurse should provide reassurance, but the primary focus should be on immediate wound care and notifying the healthcare team.
Correct Answer is C
Explanation
A. Providing more stimulation might not address the root cause of the behavior and could escalate the situation if the client becomes more agitated or confused.
B. Waiting to see if the behavior continues is not the most appropriate action, as it may delay necessary interventions. Additionally, it could increase the risk of harm to the client.
C. Calling the doctor to obtain a prescription for a restraint, if necessary, is the correct procedure. Restraints should only be used as a last resort, following proper protocols, and should always be ordered by a physician.
D. Covering the catheter so the client cannot see it might not address the underlying issue and is not an appropriate solution to managing behavior. It may also be a safety concern if it interferes with monitoring or use of the tube.
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