Question : The nurse is assessing a client the morning of the first postoperative : 2135502

1. The nurse is assessing a client the morning of the first postoperative day and notes redness and warmth around the incision. Which of the following actions should the nurse implement?

a. Obtain wound cultures.

b. Document the assessment.

c. Notify the health care provider.

d. Assess the wound every 2 hours.

2. A client with an open abdominal wound has a complete blood cell (CBC) count and differential, which indicate an increase in white blood cells (WBCs) and a shift to the left. Which of the following actions is priority as a result of this assessment data?

a. Obtain wound cultures.

b. Start antibiotic therapy.

c. Redress the wound with wet-to-dry dressings.

d. Continue to monitor the wound for purulent drainage.

3. The nurse is caring for a client with a systemic bacterial infection that has “goose pimples,” feels cold, and has a shaking chill. At this stage of the febrile response, which of the following assessments should the nurse monitor?

a. Skin flushing

b. Muscle cramps

c. Rising body temperature

d. Decreasing blood pressure

4. The nurse is caring for a young adult client who is receiving antibiotics for an infected leg wound and has a temperature of (101.8°C). Which of the following actions by the nurse is most appropriate?

a. Apply a cooling blanket.

b. Notify the health care provider.

c. Give the prescribed PRN Aspirin 650 mg.

d. Check the client’s oral temperature again in 4 hours.

5. A client’s 6 ´ 3 cm leg wound has a 2 mm black area surrounded by yellow-green semiliquid material. Which of the following dressings should the nurse use for wound care?

a. Dry gauze dressing (Kerlix)

b. Nonadherent dressing (Xeroform)

c. Hydrocolloid dressing (DuoDerm)

d. Transparent film dressing (Tegaderm)