Which of the following should the nurse recognize as a sign of possible infection in a postoperative client? (Select all that apply.)
Dry crust on the incision line
Adventitious breath sounds
Increased urine output
Decreased level of consciousness
Oral temperature of 38.3° C (101° F)
Correct Answer : B,D,E
A. Dry crust on the incision line may indicate normal healing, not necessarily infection.
B. Adventitious breath sounds can be indicative of pneumonia, a potential infection.
C. Increased urine output is not a sign of infection but may suggest other issues.
D. Decreased level of consciousness suggests a systemic issue, which could include infection affecting the central nervous system.
E. Oral temperature of 38.3° C (101° F) indicates fever which is a common sign of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. This statement reflects a sense of blame and responsibility but may not necessarily indicate a body image disturbance.
B. This statement may indicate frustration with physical therapy progress but does not directly address body image.
C. This statement reflects guilt or self-blame but may not necessarily indicate a body image disturbance.
D. This statement directly addresses the client's perception of their body image following the amputation.
Correct Answer is D
Explanation
A. While discomfort can occur, it is not an expected or acceptable part of end-of-life care. Effective pain management is a key priority, and discomfort should be addressed promptly to ensure the client’s comfort and dignity.
B. While true, this statement does not directly address the expectation of discomfort at the end of life.
C. While pain can be present in older adults, the statement does not specifically address the end-of-life context.
D.Fear of addiction is a common concern among clients and families, even at the end of life. Nurses should educate clients and families about the importance of managing pain effectively and emphasize that addiction is not a concern when opioids are used appropriately for end-of-life care. This helps alleviate anxiety and encourages adherence to prescribed pain management regimens.
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