What assessment does the nurse recognize as an inflammatory response in a surgical wound on the leg of a patient?
a. A foul drainage is coming from the wound
b. The affected leg is cooler than the other leg
c. There are raised, red, pruritic welts on the leg
d. Rubor and edema appear around the wound
ANS: D
Rubor and edema are two of the cardinal signs of an inflammatory response. Foul drainage suggests infection, the affected leg being cooler than the other leg suggests circulatory disorder, and raised, red, pruritic welts on the leg suggest allergy.
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