On the first postoperative day after spinal fusion, the nurse assesses a client and notes the following vital signs: T 39.2°C, BP 100/50 mmHg, HR 118, and RR 23. Drainage at the client's 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)Incisional drainage isn't necessarily problematic; however, the presence of glucose in this drainage is indicative of cerebrospinal fluid (CSF). A CSF leak 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. Similarly, the client's heart rate could be elevated for numerous reasons.
B)Incisional drainage isn't necessarily problematic; however, the presence of glucose in this drainage is indicative of cerebrospinal fluid (CSF). A CSF leak 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. Similarly, the client's heart rate could be elevated for numerous reasons.
C)Incisional drainage isn't necessarily problematic; however, the presence of glucose in this drainage is indicative of cerebrospinal fluid (CSF). A CSF leak 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. Similarly, the client's heart rate could be elevated for numerous reasons.
D)Incisional drainage isn't necessarily problematic; however, the presence of glucose in this drainage is indicative of cerebrospinal fluid (CSF). A CSF leak 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. Similarly, the client's heart rate could be elevated for numerous reasons.

On the First Postoperative Day After Spinal Fusion, the Nurse