On the First Postoperative Day After Spinal Fusion, the Nurse

Multiple Choice

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