On the first postoperative day after spinal fusion,the nurse assesses a client and finds temperature 39.2°C,blood pressure 100/50 mmHg,heart rate 118 bpm,and respirations 23 breathes per min.Drainage at the incision site is clear and tests positive for glucose.Which assessment parameter indicates the highest risk for surgical wound infection?
A) Temperature
B) Incisional drainage positive for glucose
C) Heart rate 118 bpm
D) Presence of incisional drainage

Question

Quizplus · Accepted Answer

A) Presence of glucose in the incisional drainage is indicative of cerebrospinal fluid (CSF). A leak of CSF increases the risk of infection of the surgical site and meninges. Temperature above 38°C is a fever. Fever may be a sign of infection anywhere in the body, not just at the surgical wound site. Heart rate could also be elevated for numerous reasons. Purulent drainage suggests wound infection. Clear drainage from a spinal incision is a sign of possible infection.
B) Presence of glucose in the incisional drainage is indicative of cerebrospinal fluid (CSF). A leak of CSF increases the risk of infection of the surgical site and meninges. Temperature above 38°C is a fever. Fever may be a sign of infection anywhere in the body, not just at the surgical wound site. Heart rate could also be elevated for numerous reasons. Purulent drainage suggests wound infection. Clear drainage from a spinal incision is a sign of possible infection.
C) Presence of glucose in the incisional drainage is indicative of cerebrospinal fluid (CSF). A leak of CSF increases the risk of infection of the surgical site and meninges. Temperature above 38°C is a fever. Fever may be a sign of infection anywhere in the body, not just at the surgical wound site. Heart rate could also be elevated for numerous reasons. Purulent drainage suggests wound infection. Clear drainage from a spinal incision is a sign of possible infection.
D) Presence of glucose in the incisional drainage is indicative of cerebrospinal fluid (CSF). A leak of CSF increases the risk of infection of the surgical site and meninges. Temperature above 38°C is a fever. Fever may be a sign of infection anywhere in the body, not just at the surgical wound site. Heart rate could also be elevated for numerous reasons. Purulent drainage suggests wound infection. Clear drainage from a spinal incision is a sign of possible infection.

On the First Postoperative Day After Spinal Fusion,the Nurse Assesses