Which of the following manifestations would the nurse expect to see with a client who has had knee surgery and who suffered a surgical infection with signs of systemic manifestations? (Select all that apply.)

Question

1. Erythema
2. WBC 14,200 mm3
3. Pain at the surgical site
4. 10% bands
5. Respiratory rate of 16

Answer 1

2. WBC 14,200 mm3
4. 10% bands

Rationale:
The client is post–surgical repair of the knee. The nurse should be able to distinguish between local reactions and systemic reactions. An elevated WBC and 10% bands are indicative of an infection. Vital sign changes typically associated with an infection include an elevation in temperature and tachycardia. Local manifestations include erythema, warmth, pain, edema, and functional impairment, whereas systemic manifestations include elevated temperature above 100.4°F, pulse greater than 90/min., respiratory rate greater than 20, and WBC greater than 12,000 mm3 or > 10% bands.