The answer to this is letter C. The fact that the patient has a high temperature may indicate that there is an infection that is taking place. When a patient has a heart rate of 88, this is actually normal especially when the person is at rest. A person who has dry dressing means that there is nothing wrong with the wound.
Wound healing by primary intention will also not work with the assessment of the nurse. Once the assessment has been done, further inspection of the patient may be necessary so that the right treatments will be given to the patient at the soonest possible time.
1. oral temperature of 101f (38.3c)-rationale: the nursing diagnosis indicates that the clients wound, which has purulent drainage, is infected. in response to the infection, the clients temperature would be elevated. a heart rate of 88 beats/minute, healing by primary intention, and a dry, intact dressing demonstrate normal assessment findings.\r\n\r\nclient needs category: physiological integrity\r\nclient needs subcategory: physiological adaptation\r\ncognitive level: application\r\n\r\nreference: taylor, c., et al. fundamentals of nursing: the art and science of nursing care, 6th ed. philadelphia: lippincott williams & wilkins, 2008, p. 1192.