Exhibits

The client is seen for a 1 week follow up appointment. The nurse is evaluating the response to the treatment for cellulitis.

Select the 3 findings consistent with a therapeutic response to interventions.

Serum blood glucose 185 mg/dL (10.2 mmol/L)

Temperature 98.8° F (37.1° C)

White blood cell count 11.2 x 103/μL (11.2 x 109/L)

Capillary refill greater than 3 seconds bilateral lower extremities

Bilateral lower extremities skin warm, dry, and pink

Pain 2 on a 0 to 10 pain scale, bilateral lower legs described as neuropathic

Answer and Explanation

Correct Answer : B,E,F

A. Serum blood glucose 185 mg/dL (10.2 mmol/L) (Incorrect): Although lower than the previous reading, it is still elevated, which can impair healing and increase the risk of infection recurrence.
B. Temperature 98.8°F (37.1°C) (Therapeutic Response): A return to a normal temperature indicates resolution of systemic infection. Fever is a sign of active infection, so its absence suggests improvement.
C. White blood cell count 11.2 x 10³/μL (11.2 x 10⁹/L) (Incorrect): This is slightly elevated, which may indicate residual inflammation or infection. A further decrease would be expected for full resolution.
D. Capillary refill greater than 3 seconds bilateral lower extremities (Incorrect): Delayed capillary refill suggests impaired circulation, which is not an indicator of a fully therapeutic response.
E. Bilateral lower extremities skin warm, dry, and pink (Therapeutic Response): Improved skin condition suggests reduced inflammation, better circulation, and healing of the cellulitis-affected area.
F. Pain 2 on a 0 to 10 pain scale, bilateral lower legs described as neuropathic (Therapeutic Response): Pain related to cellulitis typically improves with treatment. If the remaining pain is neuropathic, it suggests resolution of the acute infection.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Staphylococcus aureus abscess around a hair follicle. A furuncle, or boil, is a deep infection of a hair follicle caused by Staphylococcus aureus. It presents as a painful, pus-filled nodule due to bacterial invasion and inflammation. Poor hygiene, friction, or immune suppression can increase susceptibility.
B. Insect or spider bite that becomes infected. While insect bites can introduce bacteria into the skin, they do not directly cause furuncles. Secondary infection may occur, but furuncles specifically arise from infected hair follicles, not bites.
C. Sexual contact with an infected partner. Furuncles are not sexually transmitted infections. While skin-to-skin contact can spread Staphylococcus aureus, furuncles are not a direct result of sexual activity.
D. Inadequate blood supply to the area. Poor circulation can impair wound healing and increase infection risk, but furuncles result from bacterial infection of a hair follicle rather than ischemia.

A. Remove the ink marks of the portal after each radiation treatment. B. Apply moisture lotions daily to the radiation portal site. C. Protect the skin of the radiation portal site from sunlight exposure. D. Avoid washing the skin inside the radiation portal site.

Correct Answer is C

Explanation

A. Remove the ink marks of the portal after each radiation treatment. Ink marks should not be removed, as they help ensure precise radiation targeting during each session. The marks should remain visible until the treatment plan is complete.
B. Apply moisture lotions daily to the radiation portal site. Many lotions and creams contain ingredients that can irritate the skin or interfere with radiation therapy. Only approved, non-irritating, fragrance-free moisturizers should be used, and typically only after consulting the oncology provider.
C. Protect the skin of the radiation portal site from sunlight exposure. Radiation therapy increases skin sensitivity, making it more vulnerable to sunburn and damage. Clients should cover the treated area with loose clothing or use sunscreen (SPF 30 or higher) if sun exposure is unavoidable.
D. Avoid washing the skin inside the radiation portal site. Gentle washing with mild soap and lukewarm water is recommended to keep the area clean and reduce irritation. Harsh scrubbing, hot water, and scented soaps should be avoided.

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Exhibits The client is seen for a 1 week follow up appointment. The nurse is evaluating the response to the treatment for cellulitis. Select the 3 findings consistent with a therapeutic response to interventions.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client's skin and notices a raised nodule on the right forearm that is tender and filled with purulent secretions. The healthcare provider diagnosed the abscess as a furuncle. Which pathological etiology places the client at risk for the development of a furuncle?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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Exhibits

The client is seen for a 1 week follow up appointment. The nurse is evaluating the response to the treatment for cellulitis.

Select the 3 findings consistent with a therapeutic response to interventions.