A charge nurse is teaching newly licensed nurses about postoperative procedures following abdominal surgery. Which of the following information should the charge nurse include?
Encourage ambulation only after 48 hours post-surgery.
Instruct clients to avoid coughing to prevent wound dehiscence.
Monitor for signs of infection, such as fever or redness.
Remove surgical dressings within 12 hours post-surgery.
The Correct Answer is C
Choice A reason: Encouraging ambulation only after 48 hours delays recovery, as early ambulation (within 12-24 hours) promotes circulation, prevents thromboembolism, and aids bowel function post-abdominal surgery. This instruction is incorrect, as it contradicts evidence-based protocols for early mobilization to enhance recovery.
Choice B reason: Instructing clients to avoid coughing is inappropriate, as coughing and deep breathing prevent pulmonary complications like atelectasis post-abdominal surgery. Splinting the incision during coughing reduces discomfort and dehiscence risk, making this instruction incorrect as it increases respiratory complications.
Choice C reason: Monitoring for signs of infection, such as fever or redness, is critical post-abdominal surgery to detect complications early. Infections can delay healing and lead to sepsis. Regular assessment ensures timely intervention, aligning with evidence-based postoperative care, making this the correct information to include.
Choice D reason: Removing surgical dressings within 12 hours is not standard, as dressings typically remain for 24-48 hours or per surgeon orders to protect the wound and reduce infection risk. Premature removal increases contamination risk, making this instruction incorrect for postoperative care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: A pain level of 1 on a 0-10 scale indicates well-controlled pain, which does not directly impair wound healing. Adequate pain management supports mobility and recovery, reducing stress responses that could delay healing. This finding is not a risk factor for delayed wound healing in post-surgical clients.
Choice B reason: An oxygen saturation of 92% on room air is slightly low but not critically hypoxic. Wound healing requires adequate oxygenation, but levels above 90% are generally sufficient for tissue repair. This finding alone does not significantly indicate a risk for delayed wound healing compared to nutritional deficits.
Choice C reason: An albumin level of 2.5 g/dL (normal: 3.5-5.0 g/dL) indicates malnutrition, a major risk for delayed wound healing. Albumin is essential for tissue repair, collagen synthesis, and immune function. Low levels impair fibroblast activity and wound strength, increasing infection risk and slowing recovery in post-surgical clients.
Choice D reason: A body mass index of 22 is within the normal range (18.5-24.9) and does not indicate malnutrition or obesity, both of which can impair wound healing. Normal BMI supports adequate nutritional status for tissue repair, making this finding not a risk factor for delayed wound healing.
Correct Answer is B
Explanation
Choice A reason: Frequent nosebleeds are not linked to coarctation of the aorta, a congenital aortic narrowing. They may result from hypertension or nasal issues, but coarctation causes differential blood pressure, with high upper body pressure, not nasal vasculature changes, making this an unrelated finding.
Choice B reason: Weak femoral pulses are expected in coarctation of the aorta, as the narrowing restricts blood flow to the lower extremities. This creates a pressure gradient, with stronger upper body pulses, detectable in infants, guiding diagnosis and management of this cardiovascular defect.
Choice C reason: Increased intracranial pressure is not associated with coarctation, which affects cardiovascular dynamics, not cranial pressure. It may occur in neurological conditions, but coarctation’s primary effect is hypertension above the narrowing, not brain-related changes, making this an irrelevant finding in this context.
Choice D reason: Upper extremity hypotension is incorrect, as coarctation causes hypertension in the upper extremities due to restricted aortic flow. Blood pressure is higher above the narrowing, with strong brachial pulses, while lower extremities experience reduced flow, opposite to hypotension in the upper body.
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