The nurse is caring for a patient on the medical–surgical unit postoperative day 5. During each patient assessment, the nurse evaluates the patient for infection. Which of the following would be most indicative of infection?
A) Presence of an indwelling urinary catheter
B) Rectal temperature of 99.5ºF (37.5ºC)
C) Red, warm, tender incision
D) White blood cell (WBC) count of 8,000/mL
Ans: C
Feedback:
Redness, warmth, and tenderness in the incision area should lead the nurse to suspect a postoperative infection. The presence of any invasive device predisposes a patient to infection, but by itself does not indicate infection. An oral temperature of 99.5ºF may not signal infection in a postoperative patient because of the inflammatory process. A normal WBC count ranges from 4,000 to 10,000/mL.
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