A nurse is collecting data from four clients who have wounds. The nurse should recognize that which of the following clients has a manifestation of a wound infection?
A client who has swelling and tenderness around the wound
A client who has brown crusting over the wound
A client who has serosanguineous drainage from the wound
A client who has urticaria and itching around the wound
The Correct Answer is A
A. Swelling and tenderness around the wound are common signs of infection, indicating an inflammatory response to the presence of bacteria.
B. Brown crusting over the wound may suggest the presence of a scab or dried exudate, which is a normal part of the healing process and not necessarily indicative of infection.
C. Serosanguineous drainage is a type of wound drainage that is typically not a sign of infection but rather a mix of clear and blood-tinged fluid.
D. Urticaria and itching around the wound suggest an allergic reaction rather than a wound infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Leaving the client during a seizure can lead to injury. The nurse should stay with the client.
B. Placing a towel under the client's head helps protect the head from injury during a seizure.
C. Placing the client in the prone position can compromise the airway and increase the risk of aspiration.
D. Holding the client's arms and legs still can be difficult and may result in injury to the client or the nurse. The priority is to protect the client from injury during the seizure.
Correct Answer is A
Explanation
A. Critical pathway provides a specific, timeline-based plan of care with expected outcomes and interventions, including activity levels.
B. Standards of care are important but may not offer specific guidance for the individual client's daily activity level.
C. Guidelines may provide general recommendations but may lack specificity.
D. This is general information source but not as specific or current as the institution's critical pathway.
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