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
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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Related Questions
Correct Answer is C
Explanation
A. While monitoring urine characteristics is important for overall assessment, it may not be the priority in this situation.
B. Homan's sign is used to assess for deep vein thrombosis and may not be directly related to the client's current symptoms.
C. Elevated temperature after knee replacement surgery could indicate a potential infection, including pneumonia, so assessing lung sounds for signs of infection is a priority.
D. Diarrhea may be indicative of gastrointestinal issues but is less likely to be directly related to the client's current symptoms after knee replacement surgery.
Correct Answer is B
Explanation
A. The clinical illness phase refers to the stage when signs and symptoms of the disease are present and identifiable.
B. The incubation period is the time between exposure to a pathogen and the onset of symptoms or signs of illness. In this case, the nurse is awaiting the potential development of infection after exposure to the hepatitis B virus.
C. The prodromal period is the time when initial symptoms begin to appear but are not yet specific or fully developed.
D. The convalescent period occurs after the acute phase of illness when the patient is recovering, which does not apply to the nurse's situation immediately after needlestick exposure.
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