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 D

Explanation

A. Provide a heart-healthy low-potassium diet:

While a heart-healthy low-potassium diet is essential for managing chronic hyperkalemia and preventing future occurrences, it is not the first intervention to implement in a patient with a serum potassium level of 7.5 mEq/L and exhibiting cardiovascular changes. The effects of dietary changes on serum potassium levels are gradual and may take days to have a significant impact. In an acute situation like this, immediate interventions are needed to rapidly lower potassium levels and address the associated cardiovascular risks.

B. Prepare to administer sodium polystyrene sulfate 15g by mouth:

Sodium polystyrene sulfate is a medication used to exchange sodium for potassium in the gastrointestinal tract, effectively lowering serum potassium levels over hours to days. While it is a valid treatment for hyperkalemia, its onset of action is not immediate enough to address the urgent cardiovascular changes seen in severe hyperkalemia. Therefore, it is not the first-line intervention in this scenario.

C. Prepare the patient for hemodialysis treatment:

Hemodialysis is an effective method for rapidly lowering serum potassium levels in cases of severe hyperkalemia. However, it is a more invasive and time-consuming procedure that requires preparation, including vascular access and dialysis setup. It is typically reserved for situations where other interventions have failed or in patients with severe or refractory hyperkalemia. In the context of this scenario, where the patient has a serum potassium level of 7.5 mEq/L and is exhibiting cardiovascular changes, hemodialysis may be considered if initial interventions are not successful, but it is not the first action to implement.

A. Cluster of oral herpes sores B. Abdominal surgical incision C. Diabetic foot ulcer D. Posterior scalp wound

Correct Answer is C

Explanation

A. Cluster of oral herpes sores: Oral herpes sores typically heal within a few weeks and do not generally become chronic wounds unless there are complications or underlying immune system issues. They are more acute in nature and tend to resolve without becoming chronic.

B. Abdominal surgical incision: Surgical incisions are designed to heal within a specific timeframe, usually a few weeks to a couple of months, depending on the type of surgery and individual healing factors. While surgical wounds can sometimes have delayed healing or complications, they are not typically categorized as chronic wounds unless they fail to heal or become recurrent over an extended period.

C. Diabetic foot ulcer: Diabetic foot ulcers are highly prone to becoming chronic wounds due to the underlying pathology associated with diabetes, such as neuropathy (nerve damage), peripheral vascular disease (poor circulation), and impaired immune function. These factors can impair the normal healing process, leading to delayed healing, infection, and the potential for the wound to become chronic if not managed appropriately.

D. Posterior scalp wound: Scalp wounds can heal relatively quickly, especially with proper wound care and management. However, certain factors such as the size of the wound, depth, presence of infection, and underlying conditions can influence the likelihood of a scalp wound becoming chronic. In general, scalp wounds are less likely to become chronic compared to wounds in areas with higher risk factors, such as diabetic foot ulcers.

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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

A nurse cares for a patient who has a serum potassium of 7.5 mEq/L and is exhibiting cardiovascular changes. Which should the nurse implement first?

Correct Answer is D

Explanation

A nurse is assisting in identifying clients on the medical surgical floor with skin problems. Which of the following are most likely to become chronic wounds?

Correct Answer is C

Explanation

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