The nurse is caring for several clients on a hospital's surgical unit. Which of the following clients are at greatest risk for developing an infection?
A client age 52 who had gall bladder surgery and has osteoarthritis
A client age 18 who had plastic surgery on nose and is overweight
A client age 45 with a fractured wrist and in pain
A client age 78 with Rheumatoid arthritis who had foot surgery and a Foley catheter inserted
The Correct Answer is D
A. While gall bladder surgery carries a risk of infection, having osteoarthritis does not significantly increase the risk compared to other factors listed.
B. Plastic surgery and being overweight may increase the risk of surgical site infections, but age and comorbidities are more significant factors.
C. A fractured wrist may increase the risk of infection at the fracture site, but it is not as significant a risk factor as advanced age and comorbidities.
D. Advanced age, rheumatoid arthritis, foot surgery, and Foley catheter insertion are all factors that increase the risk of infection, making this client the most vulnerable.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E","F","H","J"]
Explanation
A. While encouraging fluid intake is generally beneficial, this action alone may not adequately address the client's respiratory distress.
B. Obtaining the client's vital signs and noting changes from previous readings is essential for assessing the client's condition and response to interventions.
C. Administering antitussive medication may not be appropriate as the client is able to expectorate secretions, and suppressing the cough may hinder clearance of secretions.
D. Positioning the client in a high-Fowler position helps improve lung expansion, aiding in respiratory effort.
E. Increasing the supplemental oxygen flow can help alleviate respiratory distress by improving oxygenation.
F. Calling the respiratory therapist for a nebulizer treatment is appropriate, especially since the client reported previous relief with this intervention.
G. Increasing IV fluids may not directly address the client's respiratory distress and should be based on fluid status and other clinical indications.
H. Documenting findings and actions taken ensures proper communication and continuity of care.
I. Contacting the Rapid Response Team may not be necessary as the client is alert and oriented and not in immediate distress.
J. Listening to the client's breath sounds allows the nurse to compare with previous findings and evaluate respiratory status.
Correct Answer is ["C","D","F","G"]
Explanation
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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