Hesi - Medical Surgical Nursing Test Study Guide Questions And Correct Answers

The nurse is assessing a client's skin for local signs of infection. Which signs does the nurse assess for? (Select all that apply.) A) Redness B) Fever C) Increased erythrocyte sedimentation rate (ESR) D) Pain E) Swelling F) Warmth {Ans: A,D,E,F Localized signs of infection include redness, warmth, pain, swelling, heat, and pus. Fever and increased ESR are systemic signs of infection.}A client has a wound on his left trochanter that is 4 inches in diameter, with black tissue at the perimeter, and bone is exposed. Which is the nurse's best action? A) Document as a stage I pressure ulcer and apply a transparent dressing. B) Document as a stage II pressure ulcer and start wet-to-dry gauze treatments. C) Document as a stage IV pressure ulcer and prepare the client for débridement. D) Document as a stage III pressure ulcer and start antibiotic therapy. {Ans: C A stage IV ulcer is one in which skin loss is full thickness, with extensive destruction, tissue necrosis, and/or damage to muscle, bone, or supporting structures. Eschar may be present. When the bone of the trochanter area is visible, tissue loss includes muscle loss. A potential intervention consists of débridement of the