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.”

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Metabolic acidosis:

Metabolic acidosis is characterized by a low pH (<7.35) and a low bicarbonate level (<22 mEq/L) due to an excess of acids in the body or a loss of bicarbonate. However, in the given ABG values, the pH is low (7.22), but the bicarbonate level is elevated (28 mEq/L), which does not align with metabolic acidosis. Therefore, metabolic acidosis is not the correct interpretation in this case.

B. Respiratory acidosis:

Respiratory acidosis occurs when there is inadequate removal of carbon dioxide (CO2) by the lungs, leading to an accumulation of CO2 in the blood and a decrease in pH. In the ABG values provided, the pH is low (7.22), and the PaCO2 is elevated (68 mm Hg), indicating respiratory acidosis as the primary disturbance. This interpretation is supported by the elevated PaCO2 and the low pH, making it the correct choice based on the given data.

C. Respiratory alkalosis:

Respiratory alkalosis results from hyperventilation, leading to excessive elimination of CO2 and a decrease in PaCO2 levels. However, in the ABG values presented, the PaCO2 is elevated (68 mm Hg), which contradicts the expected decrease seen in respiratory alkalosis. Therefore, respiratory alkalosis is not the correct interpretation of the ABG values in this case.

D. Metabolic alkalosis:

Metabolic alkalosis is characterized by a high pH (>7.45) and a high bicarbonate level (>26 mEq/L) due to excessive loss of acids or an increase in bicarbonate levels. However, in the ABG values provided, the pH is low (7.22), and the bicarbonate level is elevated (28 mEq/L), which is not consistent with metabolic alkalosis. Therefore, metabolic alkalosis is not the correct interpretation based on the given data.

A. Blood pressure B. Bowel sounds C. Level of consciousness D. Urine output E. Platelet count

Correct Answer is ["A","C","D"]

Explanation

A. Blood pressure:

Monitoring blood pressure is a crucial aspect of evaluating fluid resuscitation in burn patients. Adequate fluid resuscitation should help maintain stable blood pressure levels within an acceptable range. Hypotension (low blood pressure) can indicate inadequate fluid resuscitation, leading to poor tissue perfusion and organ function. On the other hand, hypertension (high blood pressure) may suggest fluid overload, which can lead to complications such as pulmonary edema. Therefore, regular monitoring of blood pressure helps assess the effectiveness of fluid resuscitation and guides adjustments in fluid administration rates.

B. Bowel sounds:

While bowel sounds are important indicators of gastrointestinal motility and function, they are not directly used to evaluate the success of fluid resuscitation in burn patients. Bowel sounds may be assessed for other reasons, such as postoperative recovery or gastrointestinal conditions, but they do not provide specific information about fluid resuscitation status or tissue perfusion.

C. Level of consciousness:

Assessing the client's level of consciousness is crucial during fluid resuscitation for burns. Changes in consciousness, such as confusion, lethargy, or altered mental status, can indicate inadequate tissue perfusion and oxygenation. A clear and responsive level of consciousness suggests adequate fluid resuscitation and perfusion to vital organs, while alterations in consciousness may prompt further evaluation and adjustment of fluid resuscitation strategies.

D. Urine output:

Monitoring urine output is a key parameter in evaluating fluid resuscitation in burn patients. Adequate urine output (0.5 to 1 mL/kg/hr in adults) indicates sufficient renal perfusion and function, suggesting effective fluid resuscitation. Decreased urine output or oliguria may indicate inadequate fluid resuscitation, renal impairment, or hypovolemia, requiring reassessment and potential adjustments in fluid administration rates or type of fluids used.

E. Platelet count:

Platelet count is an important component of the complete blood count (CBC) and is used to assess clotting function and risk of bleeding. However, platelet count is not specifically used to evaluate the success of fluid resuscitation in burn patients. While clotting parameters may be monitored in burn patients, including platelet count, they are not direct indicators of fluid resuscitation status or tissue perfusion. Other laboratory parameters, such as hemoglobin, hematocrit, electrolyte levels, and arterial blood gases, may be monitored to assess the effectiveness of fluid resuscitation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is caring for a client during fluid resuscitation for burns. Which of the following are used to evaluate the success of fluid resuscitation? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

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