A patient admitted to the hospital with an infectious wound in his lower leg. Which of the following will routinely be assessed by the nurse?

1. A

   Blood culture

2. B

   Blood pressure

3. C

   Temperature

4. D

   Respiration

Appeared in: NORCET 5 mains

Explanation

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• Temperature is a cardinal sign of the body's systemic inflammatory response to infection.
• Routinely monitoring temperature allows for the early detection of fever (pyrexia), a key indicator that the infection may be present or worsening.
• It is a standard, non-invasive nursing assessment performed at regular intervals for patients with known or suspected infections.
• An elevation in body temperature is a common systemic symptom of infection that can precede more severe signs like changes in blood pressure or respiratory rate.

Why Other Options Were Wrong

• Option A: A blood culture is a diagnostic laboratory test used to detect bacteria in the blood (bacteremia). It is not a routine assessment performed by a nurse at regular intervals.
• Option B: While blood pressure is a standard vital sign, it is not the most sensitive or specific indicator for a localized wound infection. Significant changes, such as hypotension, are typically later signs of complications like septic shock.
• Option D: Like blood pressure, respiratory rate is a routine vital sign, but it is not the primary indicator for a localized infection. An increased respiratory rate (tachypnea) is a sign of systemic inflammatory response syndrome (SIRS) or sepsis.

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Clinical Relevance

• Nursing practice connection: Use the key finding related to Routine nursing assessment for a patient with a localized infection to guide bedside assessment, documentation, and the next nursing action.
• The nurse's role in routinely monitoring temperature is critical for the early identification of a worsening infection, allowing for timely intervention and prevention of sepsis.
• A consistent rise in temperature should be documented and reported to the physician promptly, as it may necessitate a change in the treatment plan, such as adjusting antibiotic therapy.
• What if? If the patient's temperature is elevated and they also exhibit a low blood pressure (e.g., systolic BP below 90 mmHg) and an increased respiratory rate (e.g., above 22 breaths/min), the nurse must suspect the onset of sepsis. The priority action would be to notify the physician or rapid response team immediately and prepare to initiate sepsis protocols.

How to Approach the Question

• First, identify the key phrases in the question: 'infectious wound' and 'routinely assessed'.
• 'Infectious wound' directs your focus to the signs and symptoms of infection.
• 'Routinely assessed' implies a standard, frequent nursing action, not a specialized, physician-ordered diagnostic test.
• Evaluate the options in this context. Temperature is a direct measure of the body's systemic response to infection (fever) and is checked routinely.
• Consider the other options. Blood pressure and respiration are also routine vital signs, but their changes are often later signs of complications from infection. A blood culture is a diagnostic test, not a routine nursing assessment.
• Conclude that temperature is the most specific and fundamental routine assessment for monitoring an infectious process.

Concept Tested & Keywords

• Concept Tested: Routine nursing assessment for a patient with a localized infection.
• Stem keywords: infectious wound, routinely assessed, nurse
• Lead-in keywords: Which of the following
• Clinical cues: The presence of an 'infectious wound' is the primary clinical cue, directing the focus to signs and symptoms of infection.

Question ID

QLtZ5cuek53UiDyRtgSfHE

Copy ID

Reference Book

E6 Nursing Fundamentals Potter Perry 12e Part 2 p. 224-226

E6 Nursing Vital Signs p. 97-99