A nurse is teaching a client about serum prealbumin. Which of the following statements should the nurse include?

A. Remove the surgical dressing and obtain a culture: Removing the dressing immediately is unnecessary for routine serosanguineous drainage, which is a normal finding in the early postoperative period. Cultures are only indicated if there are signs of infection such as purulent drainage, redness, or odor.

B. Irrigate the incision with saline: Irrigation is not required for normal serosanguineous drainage and may disrupt the healing process. It is reserved for wounds with debris, infection, or specific provider orders.

C. Clean the wound with hydrogen peroxide: Hydrogen peroxide can damage healthy tissue and delay healing. It is not indicated for routine postoperative care and should be avoided for normal drainage.

D. Mark the outline of the drainage: Marking the outline of the drainage allows the nurse to monitor for changes in amount and size over time. Tracking progression helps identify potential complications such as excessive bleeding or infection and supports timely interventions.

Rationale:

• Encourage the client to avoid napping during the day: A manic client has a severely diminished drive for sleep and is at risk for physical exhaustion. Any opportunity for rest or sleep, even a brief nap, should be encouraged to protect the client's physiological health.

• Minimize environmental stimuli for the client: Manic clients are highly distractible and easily overstimulated. Reducing noise, dimming lights, and providing a private room helps decrease the "manic energy" and promotes safety and calm.

• Provide the client with high-calorie fluids every hr: The client has not eaten for an extended period and exhibits poor recall of the last meal, indicating risk of malnutrition. High-calorie fluids are an appropriate intervention to ensure adequate caloric intake and hydration, thus supporting metabolic needs during the maniac episodes.

• Weigh the client each day: Daily weight monitoring helps track nutritional status and detect early signs of fluid imbalance or rapid weight loss, which can occur in clients with poor intake or hyperactivity during mania. It also assists in evaluating effectiveness of nutritional interventions. This practice provides objective data to guide care planning and assess health risks associated with inadequate intake.