The nurse reviews the vital signs for a 45-year-old client at 0800 on 2/5. The blood pressure is 123/88 mmHg, the heart rate is 92 beats per minute, and the respiratory rate is 16 breaths per minute.
The temperature is 101.4 F (38.6 C) and the oxygen saturation is 97 Which of these clinical cues is of the most concern to the nurse?
Wound drainage.
Platelet count.
Subjective report of pain.
Elevated body temperature.
The Correct Answer is D
Choice A rationale
Wound drainage is a significant clinical sign of localized infection, especially when it is purulent or malodorous. While it provides evidence of the body's inflammatory response to pathogens, it remains a localized finding in this specific assessment. The presence of drainage alone does not immediately indicate systemic involvement as clearly as a significant change in core body temperature or other vital signs. Therefore, it is concerning but secondary to the signs indicating that the infection may be becoming systemic.
Choice B rationale
Platelet count monitoring is necessary to evaluate the client's ability to maintain hemostasis and respond to inflammation. In the context of infection, platelets can sometimes decrease if disseminated intravascular coagulation occurs or increase as an acute phase reactant. However, without a specific lab value provided in this question, it remains a theoretical concern. It does not take precedence over the actual, measured elevation in body temperature which is already currently present and indicating a systemic physiological response.
Choice C rationale
Subjective report of pain is a key indicator of tissue integrity and the inflammatory response. The client's pain level of 5/10 reflects moderate discomfort likely caused by edema and pressure from the infected wound. While pain management is a core nursing responsibility, pain is a symptom rather than a life-threatening physiological instability. In the hierarchy of clinical cues, a subjective pain score is generally prioritized lower than objective vital sign abnormalities that suggest a systemic infectious process.
Choice D rationale
Elevated body temperature of 101.4 F (38.6 C) is the most concerning cue because it suggests the infection is no longer localized and has triggered a systemic inflammatory response. Normal body temperature is approximately 98.6 F (37 C). Fever, combined with the client's report of malaise and fatigue, indicates that the wound infection may be progressing toward sepsis. This systemic manifestation requires immediate intervention, including blood cultures and potential intravenous antibiotics, to prevent further clinical deterioration and organ dysfunction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While the collection bag itself has volume markings, they are notoriously inaccurate for precise medical monitoring. These markings are often printed on flexible plastic that distorts when filled, leading to significant errors in volume estimation. The bag is intended for containment and storage of urine rather than exact measurement. Relying on this method can lead to incorrect assessments of a client's renal perfusion and overall fluid balance status in clinical settings.
Choice B rationale
A graduated cylinder or urimeter is the gold standard for measuring urine output because these devices are specifically calibrated for high precision. A urimeter is a small, hard plastic chamber attached to the drainage bag that allows for hourly monitoring of small volumes. Accurate measurement is critical for identifying early signs of acute kidney injury or fluid volume deficit. Using a rigid, calibrated container ensures that the volume recorded reflects the actual output produced by the kidneys.
Choice C rationale
A standard specimen collection cup is primarily designed for obtaining a small sample of urine for laboratory analysis, such as a urinalysis or culture. These cups generally only hold 60 to 90 mL of fluid, which is insufficient for measuring total voided volume or shift output from an indwelling catheter. Using such a small container would require multiple transfers of urine, increasing the risk of spills and exposure to biohazardous materials for the healthcare provider and environment.
Choice D rationale
A bedside commode bucket is intended for clients who can sit upright but cannot walk to the bathroom. These buckets are large and often lack the fine graduation marks required for precise clinical measurement of urine output. Using a commode bucket for a client with an indwelling catheter is inappropriate because it introduces unnecessary steps and increases the risk of contamination. Accurate output requires a smaller, more precisely calibrated vessel to ensure fluid balance is monitored correctly.
Correct Answer is A
Explanation
Choice A rationale
Supporting the client from sliding in bed helps prevent shear and friction, which are major contributors to skin breakdown and pressure injuries. Shearing occurs when the skin remains stationary against the sheets while the underlying tissue and bone move downward, damaging the deep capillary beds. By using pillows, wedges, or adjusting the bed position (such as keeping the head of the bed at or below 30 degrees), the nurse reduces the gravitational force that causes the client to slide.
Choice B rationale
Pulling a client up under the arms during repositioning is a dangerous practice that increases the risk of friction and skin tears. This method concentrates a large amount of force on a small area of skin and can also cause musculoskeletal injury to both the client and the nurse. Instead, nurses should use friction-reducing devices like draw sheets or slide boards and utilize a team approach to lift the client off the bed surface, thereby protecting the integrity of the epidermis.
Choice C rationale
While hydration is essential for maintaining skin turgor and health, carbonated drinks are not an ideal source. These beverages often contain high amounts of sugar or caffeine, which can lead to diuresis and potentially worsen dehydration. Furthermore, carbonation can cause gastric distension and discomfort. For optimal skin health, clients should be encouraged to consume water or balanced electrolyte solutions that support cellular hydration without the negative side effects associated with soda or other highly processed carbonated liquids.
Choice D rationale
Lubricating the skin with petroleum-based oils can actually be counterproductive for skin health in some contexts. These heavy oils can clog pores and trap moisture against the skin, leading to maceration, which makes the skin more fragile and prone to breakdown. While moisturization is important, it is better to use pH-balanced emollients or barrier creams specifically designed for pressure injury prevention. Additionally, petroleum products can degrade certain medical materials and increase the risk of sliding if not applied correctly.
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