Ati lpn fundamentals exam
Ati lpn fundamentals exam ( 39 Questions)
While changing a client's wound dressing, the nurse should identify which of the following signs as an indication of a wound infection?
Edema, or swelling, can be a normal response to injury as part of the inflammatory process. However, it can also be a sign of infection, especially if it is excessive or increasing. In the context of wound healing, edema should decrease over time, and persistent or worsening edema may suggest an infection.
Petechiae are small, pinpoint, red spots that are not usually associated with wound infections. They are more commonly related to blood or vascular disorders, allergic reactions, or causes of increased venous pressure.
Urticaria, also known as hives, is typically a sign of an allergic reaction and not an infection. It presents as raised, itchy welts on the skin and is usually related to an immune response to a substance or allergen, rather than an infectious process.
Crusting over granulated tissue can indicate a wound infection. Granulation tissue is new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process. It is normally red or pink and does not have a crust. If a crust forms over it, especially if it is yellow or green, it may be composed of dried pus and is a sign of infection.
Choice A reason: Edema, or swelling, can be a normal response to injury as part of the inflammatory process. However, it can also be a sign of infection, especially if it is excessive or increasing. In the context of wound healing, edema should decrease over time, and persistent or worsening edema may suggest an infection.
Choice B reason: Petechiae are small, pinpoint, red spots that are not usually associated with wound infections. They are more commonly related to blood or vascular disorders, allergic reactions, or causes of increased venous pressure.
Choice C reason: Urticaria, also known as hives, is typically a sign of an allergic reaction and not an infection. It presents as raised, itchy welts on the skin and is usually related to an immune response to a substance or allergen, rather than an infectious process.
Choice D reason: Crusting over granulated tissue can indicate a wound infection. Granulation tissue is new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process. It is normally red or pink and does not have a crust. If a crust forms over it, especially if it is yellow or green, it may be composed of dried pus and is a sign of infection.
