A nurse is caring for a client who had a surgical repair of an abdominal aortic aneurysm 3 days ago. The client's vital signs are temperature 38.3°C (100.9°F), heart rate 80/min, respirations 16/min, and blood pressure 128/76 mm Hg. Which of the following actions is the nurse's priority?
Notify the surgeon of the temperature elevation.
Encourage the client to drink more fluids.
Assess the surgical incision for signs of infection.
Monitor vital signs every 4 hr.
The Correct Answer is C
Choice A rationale:
Notifying the surgeon of the temperature elevation is important, but it is not the nurse's priority. A temperature elevation after abdominal surgery could be a sign of infection, but the immediate action should be to assess the surgical incision for any signs of infection.
Choice B rationale:
Encouraging the client to drink more fluids is a good practice to maintain hydration and promote recovery after surgery. However, it is not the nurse's priority in this situation. The elevated temperature and potential infection take precedence over increasing fluid intake.
Choice C rationale:
This is the correct answer because the nurse's priority is to assess the surgical incision for signs of infection. An elevated temperature is a significant finding after surgery, and it may indicate a surgical site infection, which requires prompt assessment and intervention.
Choice D rationale:
Monitoring vital signs every 4 hours is an essential nursing intervention after surgery, but it is not the priority when the client has an elevated temperature and a recent surgical incision.
The nurse must first assess for signs of infection before proceeding with routine vital sign monitoring.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
(Potassium level) Lovastatin is a medication used to treat high cholesterol levels. While potassium levels are important to monitor for certain conditions, they are not directly related to the initiation of lovastatin therapy. Therefore, this is not the correct choice for diagnostic testing before starting the medication.
Choice B rationale:
(Hemoglobin level) Hemoglobin levels are important to assess for anemia or other blood disorders. However, they are not specifically required before starting lovastatin therapy. Therefore, this is not the correct choice for diagnostic testing before starting the medication.
Choice C rationale:
(Kidney function tests) While kidney function tests are essential for many medications to ensure proper excretion and avoid toxicity, they are not directly related to the initiation of lovastatin therapy. Therefore, this is not the correct choice for diagnostic testing before starting the medication.
Choice D rationale:
(Liver function tests) Liver function tests are crucial before starting lovastatin therapy. Lovastatin is metabolized in the liver, and it can potentially cause liver damage or abnormalities in liver enzymes. Monitoring liver function helps detect any pre-existing liver conditions and ensures the safe use of the medication. Therefore, this is the correct choice for diagnostic testing before starting the medication.
Correct Answer is C
Explanation
Choice A rationale:
Using fingers to remove loose tissue is not an appropriate action for the nurse to take when providing hydrotherapy for a burn wound. This action can cause further trauma to the wound and increase the risk of infection.
Choice B rationale:
Opening small blisters to expose air is contraindicated in burn wound management. The blister roof provides a natural barrier against infection, and puncturing them increases the risk of infection and delays the healing process.
Choice C rationale:
The correct answer is to wash the burn with a mild soap. Cleaning the burn wound with mild soap and water helps remove debris and minimize the risk of infection without causing additional damage.
Choice D rationale:
Applying wet-to-dry dressings is an outdated and inappropriate practice for burn wound care. Wet-to-dry dressings can be painful, disrupt wound healing, and increase the risk of infection. Modern burn wound care focuses on maintaining a moist environment to support optimal healing.
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