Which of the following is a common sign of wound sepsis?

Normal white blood cell count

Fever and chills

Decreased pain at the wound site

Redness and swelling

Answer and Explanation

The Correct Answer is B

A.   Normal white blood cell count: In wound sepsis, the white blood cell count is typically elevated as part of the body's immune response to infection, not normal.
B.   Fever and chills: Fever (hyperthermia) and chills are common signs of systemic infection, including wound sepsis. They indicate an inflammatory response and activation of the body's defense mechanisms.
C.   Decreased pain at the wound site: Increased pain at the wound site is more commonly associated with wound infection, not decreased pain.
D.   Redness and swelling: Redness (erythema) and swelling (edema) are local signs of inflammation and can be present in infected wounds, but they are not specific to wound sepsis and may occur in non-infected wounds as well.

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Correct Answer is A

Explanation

A. Obtain a sputum culture: Obtaining a sputum culture helps identify the causative organism of pneumonia, which guides appropriate antibiotic therapy.
B. Cough and deep breathe every 6 hours: While coughing and deep breathing exercises are important for preventing complications such as atelectasis, they are not specific to pneumonia treatment and may not be appropriate for all patients with pneumonia.
C. Encourage fluid intake of 1500 mL/day: Adequate fluid intake is generally recommended for overall health but is not a specific intervention for pneumonia treatment.
D. Position the client prone: Positioning the client prone is not a standard intervention for pneumonia treatment. Depending on the severity and type of pneumonia, the client's positioning may vary, but prone positioning is not routinely recommended.

A. Pupil size and reaction B. Heart rate and blood pressure C. Respiratory rate and oxygen saturation D. Skin turgor and moisture

Correct Answer is D

Explanation

A. Pupil size and reaction: Pupil size and reaction are typically assessed to monitor neurological function and are not directly related to tissue integrity.
B. Heart rate and blood pressure: Heart rate and blood pressure are vital signs that provide information about cardiovascular function but do not specifically assess tissue integrity.
C. Respiratory rate and oxygen saturation: Respiratory rate and oxygen saturation are indicators of respiratory function and oxygenation status and are not directly related to tissue integrity.
D. Skin turgor and moisture: Skin turgor, the skin's ability to return to its normal shape after being pinched, and moisture levels are important assessments for monitoring tissue hydration and integrity. Changes in skin turgor and moisture can indicate dehydration, which can impair tissue integrity and wound healing.

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Which of the following is a common sign of wound sepsis?

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Naxlex Comprehensive Predictor Exams

A nurse is assisting in the plan of care for a client showing signs of pneumonia. Which of the following nursing actions should be included?

Correct Answer is A

Explanation

Which of the following assessments should be performed to monitor for impaired tissue integrity?

Correct Answer is D

Explanation

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