NCLEX-PN

●​ Prodromal Malaise: This is a general feeling of discomfort or unease that can precede the onset of more specific symptoms. ●​ Tachypnea: Rapid breathing is often observed in clients with infections, as the body tries to deliver more oxygen to tissues and remove carbon dioxide. ●​ Tachycardia: An increased heart rate can be a response to fever and the body's increased demand for oxygen. ●​ Nausea and Vomiting: Gastrointestinal symptoms like nausea and vomiting can occur during some infections. ●​ Anorexia: Loss of appetite is common when the body is fighting off an infection. ●​ Confusion: Infections, particularly in elderly clients, can lead to confusion and altered mental status. ●​ Incontinence: Urinary or fecal incontinence may result from changes in mental status or physical function during infection. ●​ Abdominal Cramping and Diarrhea: Gastrointestinal infections can cause abdominal pain and diarrhea. Nurses play a crucial role in monitoring clients for these signs and symptoms of infection. They should also closely watch diagnostic laboratory results, which may include an elevated sedimentation rate , increased white blood cell count, elevated C-reactive protein levels, and altered blood viscosity , among other markers. Wound Care and Dressing Changes Wound care, as well as the process of cleaning and changing dressings, necessitates strict adherence to surgical asepsis to maintain sterility. As a result, these delicate procedures cannot be delegated to unlicensed nursing staff , such as nursing assistants. Wound care primarily involves the thorough cleansing and proper dressing of the wound. The cleaning solutions utilized for wound care encompass sterile normal saline and other solutions, some of which may include antiseptics to prevent infection. The cleansing procedure starts from the cleanest part of the wound and progresses outward to the more contaminated areas, all while using gauze to carefully eliminate exudate and debris. Each gentle wipe of the wound requires fresh sterile gauze to ensure minimal disruption to the newly forming granulating tissue. Additionally, wounds can be irrigated with sterile solutions to cleanse them, prevent infection, and facilitate optimal healing. As discussed earlier in the section "Performing a Skin Assessment and Implementing Measures to Maintain Skin Integrity and Prevent Skin Breakdown," nurses regularly assess the wound and its surroundings. This assessment encompasses factors such as color, size, location, odor, underlying tissue, and the characteristics of wound drainage or exudate, including its amount and color. Wound

531

© 2025 ACHIEVE ULTIMATE CREDIT-BY-EXAM GUIDE | NCLEX-PN ​

​

​

​

​