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 key vital sign that is routinely monitored by nurses for all patients, especially those with a known infection.
• Fever (an elevated temperature) is a primary systemic response to infection, even if the infection is localized to a wound.
• According to nursing fundamentals, fever serves as an important mechanism that enhances the immune system's ability to fight infection (SRC_1).
• Routinely assessing temperature allows for the early detection of a worsening condition or the development of systemic complications like sepsis, enabling prompt intervention.

Why Other Options Were Wrong

• Option A: A blood culture is a diagnostic laboratory test, not a routine assessment performed by a nurse at the bedside. It requires a physician's order.
• Option B: While blood pressure is a routine vital sign, a significant change (like hypotension) is typically a later sign indicating a complication such as septic shock, rather than an early indicator of a localized wound infection.
• Option D: Similar to blood pressure, the respiratory rate is a standard vital sign. An increased rate (tachypnea) can be a sign of systemic illness or sepsis, but it is not the most specific routine assessment for monitoring a localized wound infection.

Related Visual

• Visual 1: Infographic: Signs of Local vs. Systemic Infection. This would visually differentiate localized signs (redness, swelling, pus at the wound site) from systemic signs (fever, tachycardia, hypotension), clarifying why temperature is a key systemic indicator.
• Visual 2: Flowchart: Nursing Assessment for Infection. This could show the decision-making process, starting with routine vital signs (highlighting temperature) and escalating to other assessments (like BP, RR) and notifications (for blood cultures) if systemic signs appear.

Clinical Relevance

• Nursing practice connection: Use the key finding related to Routine nursing assessment for a patient with an infectious wound to guide bedside assessment, documentation, and the next nursing action.
• A nurse's primary role in managing a patient with an infection is early identification of deterioration. Routinely monitoring temperature is a fundamental and critical part of this surveillance.
• Failure to recognize and report a persistent or rising fever can delay treatment and lead to severe complications like sepsis, which has a high mortality rate.
• What if? If the patient with the wound infection was elderly or immunocompromised, they might not mount a strong fever response. In this case, the nurse must be extra vigilant for other, more subtle signs of sepsis, such as new-onset confusion, lethargy, or a slight increase in respiratory rate.

How to Approach the Question

• First, analyze the question to identify the key concepts: 'infectious wound' and 'routinely assessed by the nurse'.
• The term 'routinely assessed' points towards a standard, frequent nursing action, like taking vital signs.
• Differentiate between a nursing assessment and a diagnostic test. A blood culture is a diagnostic test ordered by a doctor, which eliminates that option.
• Evaluate the remaining options: Blood pressure, Temperature, and Respiration. All are vital signs routinely checked by nurses.
• Consider which of these vital signs is the most direct and common indicator of an infection. Fever (elevated temperature) is a classic, cardinal sign of the body fighting an infection.
• Conclude that while BP and respiration are important, temperature is the most specific and primary vital sign to monitor in the context of an infectious process.

Concept Tested & Keywords

• Concept Tested: Routine nursing assessment for a patient with an infectious wound.
• Stem keywords: infectious wound, lower leg, routinely assessed, nurse
• Lead-in keywords: Which of the following
• Clinical cues: The presence of an 'infectious wound' is the key clinical detail, directing focus towards signs of infection.

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