A nurse is preparing a patient for discharge after surgery. The patient needs to change a large dressing and manage a drain at home. What instruction by the nurse is most important?
“Call your surgeon if you have any questions at home.”
”Eat a diet high in protein, iron, zinc, and vitamin C.”
“Wash your hands before touching the drain or dressing."
“Be sure you keep all your postoperative appointments.”
The Correct Answer is C
A. “Call your surgeon if you have any questions at home.”
This instruction is important as it encourages the patient to seek help and clarification if they have any concerns or questions about their postoperative care at home. However, while communication with the surgeon is essential, it is not as immediately critical as ensuring proper hand hygiene when dealing with wound care and drain management.
B. ”Eat a diet high in protein, iron, zinc, and vitamin C.”
Nutritional advice is crucial for postoperative recovery, as a balanced diet high in protein, iron, zinc, and vitamin C can promote wound healing and overall recovery. However, while important for long-term recovery and healing, dietary recommendations do not directly address the immediate risk of infection or complications associated with wound care and drain management.
C. “Wash your hands before touching the drain or dressing."
This instruction is the most important in this context because proper hand hygiene is crucial for preventing infections during wound care and drain management. Clean hands significantly reduce the risk of introducing harmful bacteria or contaminants to the surgical site, which can lead to infections and other complications. Ensuring that the patient washes their hands before touching the drain or dressing is a fundamental measure for promoting wound healing and preventing postoperative complications.
D. “Be sure you keep all your postoperative appointments.”
Keeping postoperative appointments is important for ongoing assessment, monitoring, and follow-up care. However, while essential for overall recovery and management of postoperative issues, it is not as immediate or directly related to the patient's ability to manage their dressing and drain at home.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A 60-year-old client with gastritis:
Gastritis is inflammation of the stomach lining and typically does not directly increase the risk of skin infections. However, if the gastritis is due to an underlying condition that affects the immune system, such as an autoimmune disorder, the client may have a slightly higher risk of infections, including skin infections, compared to a healthy individual of the same age. Overall, gastritis alone is not a significant risk factor for skin infections compared to the other options.
B. A 20-year-old client with a closed tibia fracture:
A closed tibia fracture refers to a broken shinbone that does not break the skin. While fractures themselves do not necessarily increase the risk of skin infections, they can indirectly contribute to infection risk if there are complications such as open wounds, surgical procedures, or prolonged immobilization. In this case, because the fracture is closed and presumably not complicated by open wounds or surgery, this client is not significantly prone to skin infections compared to the other options.
C. A 55-year-old client taking an ACE inhibitor:
ACE (angiotensin-converting enzyme) inhibitors are medications commonly used to treat conditions like high blood pressure and heart failure. While these medications can cause side effects like a dry cough or skin rash in some individuals, they do not directly increase the risk of skin infections. Unless the client experiences a severe allergic reaction or develops a rash that becomes infected, the use of ACE inhibitors alone is not a major risk factor for skin infections compared to the other options.
D. A 35-year-old client receiving chemotherapy:
Chemotherapy is a treatment for cancer that works by targeting rapidly dividing cells, including cancer cells but also affecting some healthy cells like those in the bone marrow responsible for producing white blood cells. As a result, chemotherapy can significantly weaken the immune system, leading to a higher risk of infections, including skin infections. Patients undergoing chemotherapy are particularly susceptible to bacterial, fungal, and viral infections due to their compromised immune response. Therefore, the 35-year-old client receiving chemotherapy is the most prone to skin infections among the options given due to their weakened immune system.
Correct Answer is D
Explanation
A. Cardiac arrest related to septic shock:
Septic shock can occur in burn patients due to the breakdown of the skin barrier, which allows pathogens to enter the bloodstream and cause systemic infection. However, while septic shock is a serious complication of burn injuries, it is not the primary cause of death in the emergent phase. Septic shock can lead to multiple organ failure and contribute to mortality, but it is often a later complication rather than an immediate cause in the emergent phase.
B. Infection:
Infections are a significant concern in burn patients, especially as the burn wound provides an ideal environment for bacterial growth. However, infections typically contribute more significantly to mortality in the later phases of burn care rather than in the emergent phase. In the emergent phase, hypovolemic shock and other immediate complications have a greater impact on mortality.
C. Adrenal failure:
Adrenal failure, specifically acute adrenal insufficiency or Addisonian crisis, can occur in burn patients due to the stress response and corticosteroid depletion. While adrenal insufficiency is a concern in severe burn cases, it is not the primary cause of death in the emergent phase requiring referral to a burn center.
D. Hypovolemic shock and renal failure:
Hypovolemic shock is a critical concern in the emergent phase of burn trauma because burns can lead to significant fluid loss and electrolyte imbalances. Hypovolemic shock results from insufficient circulating blood volume, leading to inadequate perfusion of organs and tissues, which can be life-threatening. Additionally, renal failure can develop due to hypovolemia, decreased cardiac output, and the release of inflammatory mediators, leading to acute kidney injury (AKI). Hypovolemic shock and subsequent renal failure are major contributors to mortality in the emergent phase of burn trauma, necessitating prompt referral to a burn center for specialized care.
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