NCLEX Perioperative 2023 WITH COMPLETE SOLUTIONS GRADED A+ (PROVIDES FULL EXPLANATIONS)

The nurse checks the postoperative client for signs of infection. Which observations are indicative of a potential infection? Select all that apply. 1.Slight redness along the incision 2.The presence of purulent drainage 3.A temperature of 98.8° F (37.1° C) 4.The client states that he feels cold. 5.The client states that the incision itches. 6.Tender firmness palpable around the incision - ANS 2.The presence of purulent drainage 6.Tender firmness palpable around the incision Rationale:A wound infection occurs when healing is delayed and pathogens such as bacteria grow in the wound. Signs and symptoms of a wound infection include warmth, redness, swelling, and tenderness of skin around the incision. The client may have fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique or a wound that was contaminated before surgical exploration; it appears 3 to 6 days after surgery. Slight redness along an incision is a sign of inflammation and should be monitored to determine whether it progresses. A temperature of 98.8° F (37.1° C) is not an abnormal finding in a postoperative client. Itching around a wound may be from irritation or dryness and is not associated with infection. The fact that a client feels cold is not indicative of an infection, although chills and fever are signs of infection. The room temperature may be too cold for client comfort. Test-Taking Strategy(ies):Focus on the subject, wound infection. Noting the words purulent, tender, and hardness will direct you to the correct options.Review:The signs of a wound infection.Color Key:Cyan = StrategyMagenta = Content Review The nurse is assisting in providing surgical instructions to a preoperative client who will have abdominal surgery. Which instructions would be appropriate to include in the preoperative plan of care? Select all that apply.