Certified Medical-Surgical Registered Nurse Practice Exam

Which sign or symptom is most indicative of infection in a postoperative patient?

1. Presence of an indwelling urinary catheter

2. Rectal temperature of 100° F (37.8° C)

3. Redness, warmth, and tenderness at the incision site

4. WBC count of 8,000/mL

The correct answer is: Redness, warmth, and tenderness at the incision site

The presence of redness, warmth, and tenderness at the incision site is considered the most indicative sign of infection in a postoperative patient. These symptoms are characteristic of inflammation, which often occurs in response to infection. When assessing a postoperative patient, nurses are vigilant for signs of infection that can complicate recovery, and local symptoms around the incision are key indicators. Understanding the mechanics of wound healing and the body's response to surgery is crucial. The inflammatory response aims to protect and heal the area, and while some redness and warmth can be part of normal healing, the presence of these symptoms along with tenderness specifically points more toward an infectious process, especially if it is accompanied by other systemic signs or symptoms. In contrast, an indwelling urinary catheter can increase the risk for urinary tract infections but is not a definitive sign of infection itself. A rectal temperature of 100° F may indicate a mild fever, which can occur postoperatively due to various causes such as atelectasis or dehydration, not solely infection. A white blood cell (WBC) count of 8,000/mL is typically within the normal range for adults and does not by itself indicate infection, given that the body may not mount a strong immune response in the early stages of infection