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 B
Explanation
A. Species immunity refers to immunity shared by all members of a species to certain pathogens, which is not the case here.
B. Natural immunity refers to immunity that is acquired naturally, often through exposure to a pathogen such as contracting mumps during childhood.
C. Artificially acquired immunity is acquired through deliberate actions such as vaccination, which does not apply in this scenario.
D. Passive immunity is temporary immunity transferred from one individual to another, such as through maternal antibodies passed to an infant, which does not apply in this case.
Correct Answer is A
Explanation
A. Standard precautions include the use of gloves, gowns, masks, eye protection, or face shields, depending on the anticipated exposure. Wearing gloves and a gown is appropriate when there is a risk of exposure to bodily fluids, which can occur when bathing a client with open skin lesions. This approach helps prevent the transmission of infections.
B. The UAP does not need to wear gloves when taking blood pressures on all clients unless there is a risk of exposure to blood or body fluids.
C. While wearing gloves, a gown, and an N95 mask may be appropriate for certain situations involving airborne precautions (e.g., tuberculosis), it is not necessary for standard precautions when caring for a client with diarrhea.
D. This is an overuse of gloves and does not align with standard precautions, which recommend using gloves only when there is or may be contact with blood, bodily fluids, secretions, excretions, contaminated items, or mucous membranes.
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