A graduate nurse (GN) is caring for a client with right lower leg cellulitis that is seeping clear fluid. Which action by the GN requires intervention by the supervising nurse? A)Applying a warm compress to the affected extremity B)Maintaining the affected leg flat on the bed C)Marking and dating the reddened areas D)Wearing a gown and gloves while bathing the client

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11ecbb05_cb63_ab1c_b433_55e2ac6b7f51_MD0009_00 Cellulitis is inflammation of the subcutaneous tissues that is typically caused by bacterial infection (eg, Staphylococcus aureus, group A Streptococcus) resulting from an insect bite, cut, abrasion, or open wound. Cellulitis is characterized by redness, edema, pain, and fever. Nurses caring for clients with cellulitis should ensure that the affected extremity is elevated when the client is sitting or lying down to promote lymphatic drainage. Flat or dependent positioning may worsen edema, which delays recovery and contributes to pain (Option B). In addition, clients with weeping or draining wounds must be protected from prolonged exposure to moist or soiled linens as this exposure promotes tissue injury and infection. (Option A) Applying warm compresses promotes circulation to the area of infection, alleviates discomfort, and helps reduce edema. (Option C) Daily marking and dating of reddened areas assist with monitoring improvement or worsening of the infection. Redness that progresses past the marked areas indicates ineffective antibiotic therapy and should be reported to the health care provider. (Option D) Although standard precautions are typically sufficient for cellulitis, a gown and gloves are worn when contact with body fluids (eg, urine, stool) or potentially infectious drainage is expected, such as during bathing. Educational objective: Nurses caring for clients with cellulitis should ensure that the affected extremity is elevated to reduce edema. Additional nursing interventions include applying warm compresses, monitoring the size of the cellulitis, and using personal protective equipment to prevent infection transmission.

A Graduate Nurse (GN) Is Caring for a Client with Right