Question

The nurse is gathering assessment data. Which cues form a pattern of an existing problem?

1) Wound drainage purulent and foul smelling
2) Fluid intake 800 mL for last 8 hours
3) Client states, 'I'm worried I won't be able to return to work next week.'
4) Skin surrounding wound is hot and tender to the touch
5) Oral temperature 120°F
6) F. Outside dressing fully saturated prior to removing

Answer 1

The assessment cues that form a pattern of an existing problem include purulent and foul-smelling wound drainage, skin that is hot and tender around the wound, and a fully saturated dressing—these suggest an infection.

Step-by-step explanation:

The student is asking which cues form a pattern that indicates an existing problem when a nurse is gathering assessment data. The cues that suggest an existing problem include: 1) Wound drainage purulent and foul smelling; 4) Skin surrounding wound is hot and tender to the touch; and 6) Outside dressing fully saturated prior to removing.

These signs are indicative of an infection, possibly a serious bacterial infection, which may require medical treatment such as antibiotics. This pattern aligns with the clinical focus on various patients who show signs of infection, such as increased redness, swelling, fever, and purulent discharge, which are commonly treated with topical or systemic antimicrobial therapy.

Signs like 'client's worry about returning to work' are subjective and more related to the client's emotional state, and fluid intake is a general health indicator but not specific to infection. Lastly, an oral temperature of 120°F is physiologically implausible as it would be fatal; hence it is likely a typo or mistake. Normal oral temperature is approximately 98.6°F, and a fever would be indicated by a temperature several degrees above this.