Question

The nurse assesses the sternotomy incision of a client on the third day after cardiac surgery. The incision shows some slight puffiness along the edges and is nonreddened, with no apparent drainage. The client's temperature is 99°F (37.2°C) orally. The white blood cell count is 7500 mm3 (7.5 × 109/L). How should the nurse interpret these findings?

1.Incision is slightly edematous but shows no active signs of infection.
2.Incision shows early signs of infection, although the temperature is nearly normal.
3.Incision shows no sign of infection, although the white blood cell count is elevated.
4.Incision shows early signs of infection, supported by an elevated white blood cell count.

Answer 1

The nurse should interpret the sternotomy incision as slightly edematous without active signs of infection, given the lack of redness, normal white blood cell count, no drainage, and only slightly elevated temperature.

Step-by-step explanation:

The nurse should interpret these findings as: 1.Incision is slightly edematous but shows no active signs of infection. The incision's slight puffiness indicates edema, a common postoperative reaction. The absence of redness, drainage, and a normal white blood cell count (7500 mm3 or 7.5 × 109/L) are signs that there is no active infection at present. Additionally, the temperature of 99°F (37.2°C) is only slightly elevated and can be expected after surgery due to the body's response to trauma and healing.

Step-by-step explanation:

The nurse should interpret these findings as option 1: The incision is slightly edematous but shows no active signs of infection.

The slight puffiness along the edges of the incision indicates mild edema. The absence of redness and drainage suggests that there is no active infection present. The mildly elevated temperature of 99°F and the normal white blood cell count of 7500 mm3 further support the interpretation that there is no infection.