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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 D

Explanation

A. While standard precautions should be followed, the use of sterile gloves for routine care related to pertussis is not necessary.
B. Placing a surgical mask on the client during transportation may help prevent the spread of respiratory droplets but is not a comprehensive infection control measure.
C. Wearing a gown for all client cares is unnecessary and may not be practical.
D. Wearing a mask when providing care within 10 feet of the client helps reduce the risk of droplet transmission of pertussis.

A. Reservoir B. Portal of entry C. Characteristics of the organism D. Portal of exit

Correct Answer is B

Explanation

A. The reservoir is the source of infectious agents, not the method by which they enter the body.
B. Meticulous sterile technique during wound care procedures helps prevent microorganisms from entering the body, thereby controlling the portal of entry for potential pathogens.
C. Characteristics of the organism refer to factors such as virulence and pathogenicity, which influence the organism's ability to cause infection but are not directly controlled by sterile technique during wound care.

D. The portal of exit is the route by which infectious agents leave the reservoir, such as through respiratory secretions or bodily fluids, and is not directly controlled by sterile technique during wound care.

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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

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include?

Correct Answer is D

Explanation

A nurse who uses meticulous sterile technique when performing wound care procedures is attempting to control which link in the chain of infection?

Correct Answer is B

Explanation

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