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A nurse is completing a head-to-toe assessment on a client who is 3 days post-operative from a right mastectomy. Which of the following should the nurse recognize as a sign of possible infection? Select all that apply.

Client reports no pain

Oral temperature of 98.9 degrees F

Decreased level of consciousness

WBCs are 15,000

Scab forming on incision line

Crackles in bilateral lung bases

Incision is red and warm to touch

Answer and Explanation

Correct Answer : C,D,F,G

A. The absence of pain does not necessarily indicate the absence of infection.

B.   An oral temperature of 98.9 degrees F is within the normal range and does not indicate infection.
C.   Decreased level of consciousness can be a sign of systemic infection, especially if accompanied by other symptoms.
D.   An elevated white blood cell count (WBC) is indicative of an inflammatory response, which can occur in infection.
E.   A scab forming on the incision line is a normal part of wound healing and does not necessarily indicate infection.
F.   Crackles in bilateral lung bases may indicate a possible infection.

G. Redness and warmth at the incision site are signs of inflammation and can indicate infection.

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Correct Answer is A

Explanation

A. In this phase, the client develops non-specific symptoms such as malaise, fever, and body aches, indicating the onset of the disease.
B. This phase occurs after the pathogen enters the body but before symptoms appear.

C. This phase is marked by recovery and the resolution of symptoms.

D. This phase refers to the period during which the disease can be transmitted to others.

A. make sure the client's room has HEPA filtration B. wear a mask when providing the client care C. wear a gown when providing the client care D. make sure the client's room has negative airflow

Correct Answer is B

Explanation

A. HEPA filtration is not typically required for clients on droplet precautions.
B. Droplet precautions require healthcare workers to wear a mask when providing care to prevent the transmission of respiratory droplets.
C. Gowns are not typically required for clients on droplet precautions unless there is potential for contact with body fluids.
D. Negative airflow is not specifically indicated for clients on droplet precautions; it is more commonly associated with airborne precautions.

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A nurse is completing a head-to-toe assessment on a client who is 3 days post-operative from a right mastectomy. Which of the following should the nurse recognize as a sign of possible infection? Select all that apply.

Nursing Test Bank

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