A nurse is replacing the dressing for a client who is postoperative following thoracic surgery.
When assessing the surgical wound, which of the following findings should the nurse identify as an indication of infection?

Crusting along the incision line.

Temperature of 37.2° C (99° F).

Pink coloration of the incision line.

Swelling extending 3.8 cm (1.5 in) from the incision.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Crusting along the incision line is the result of dried serous fluid and blood, which is a normal part of the wound healing process during the inflammatory phase. This finding alone is not indicative of a surgical site infection, which is characterized by other signs.

Choice B rationale

A temperature of $37.2^\circ C$ ($99^\circ F$) is within the normal range for body temperature ($36.1^\circ C$ to $37.2^\circ C$ or $97^\circ F$ to $99^\circ F$). An elevated temperature, specifically a fever, is a systemic sign of infection. A low-grade fever might be a subtle sign, but this temperature is not high enough.

Choice C rationale

Pink coloration of the incision line is a normal finding in the early stages of wound healing, representing angiogenesis, the formation of new blood vessels. This process is crucial for tissue repair and does not indicate a surgical site infection, which is typically characterized by erythema and warmth.

Choice D rationale

Swelling, or edema, is a classic sign of inflammation and infection. While some minor swelling is normal, swelling that extends significantly beyond the wound margins, such as 3.8 cm (1.5 in), indicates a heightened inflammatory response potentially due to bacterial proliferation and infection. *.

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

Why Safety Comes First

The client presents with multiple red flags for physical abuse and neglect, including bruises in various stages of healing, a fracture, and concerning behavior around the adult child.
Ensuring the client is in a safe environment is the top priority to prevent further harm and initiate protective interventions.

Why Nutritional Status Is Next

The client reports limited food availability and has a low BMI (18.3), suggesting possible malnutrition.
Addressing nutritional needs is essential for recovery and overall well-being, especially in older adults who are vulnerable to rapid health decline.

A. A corn tortilla with black beans. B. Low sodium vegetable soup with barley. C. Whole wheat pasta with shrimp. D. A bologna sandwich on rye bread.

Correct Answer is B

Explanation

Choice A rationale

Sitting in chairs with low, soft backs can worsen osteoarthritis symptoms and increase joint stress. Low chairs require more force from the hips and knees to stand up, which can strain these joints. Soft backs provide inadequate support, leading to poor posture and increased stress on the spine and other joints. Proper joint protection involves maintaining good posture and minimizing strain on affected joints.

Choice B rationale

Using both hands to hold objects distributes the weight and stress evenly across multiple joints, such as those in both wrists and hands, thereby reducing the workload on any single joint. This technique minimizes the risk of joint deformation and pain associated with osteoarthritis by preventing excessive force from being applied to a single joint, a key principle of joint protection.

Choice C rationale

Pushing up from a bed with fingers puts a concentrated, high-impact force on the small joints of the fingers, which are often affected by osteoarthritis. This action can lead to pain, inflammation, and potential deformity over time. Instead, individuals should use their palms or forearms to push up, distributing the force over a larger, stronger surface area.

Choice D rationale

Turning doorknobs clockwise or in any specific direction with a forceful grip can exacerbate joint pain and strain in the fingers and wrist. This motion places significant torque on the affected joints. To protect joints, clients should be advised to use lever-style doorknobs or adaptive devices that require less grip strength and a different motion. *.

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A nurse is replacing the dressing for a client who is postoperative following thoracic surgery. When assessing the surgical wound, which of the following findings should the nurse identify as an indication of infection?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse should first address the client’s dropdown followed by the client’s dropdown.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

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Correct Answer is B

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A nurse is replacing the dressing for a client who is postoperative following thoracic surgery.
When assessing the surgical wound, which of the following findings should the nurse identify as an indication of infection?