A patient is admitted to the cardiac unit.


Everyone admitted to the cardiac unit will have an EKG done unless otherwise ordered. This is an example of which type of order?

Choice A rationale:

Irrigating with sterile saline before swabbing can dilute the wound specimen and reduce the accuracy of the culture results. This is because the saline can wash away some of the bacteria that are present in the wound, making it more difficult to identify the specific bacteria that are causing the infection.

Additionally, swabbing the center of the wound may not collect a representative sample of the bacteria present, as bacteria can often be found in higher concentrations at the edges of the wound. This is because the edges of the wound are often where the tissue is most damaged and where the bacteria are able to enter the body more easily.

Choice B rationale:

Obtaining a sample of the drainage from the dressing on the wound may not be as accurate as collecting a sample directly from the wound. This is because the drainage may contain bacteria from the surrounding skin or environment, which could contaminate the culture results.

Additionally, the drainage may not contain a representative sample of the bacteria present in the wound, as some bacteria may not be able to drain out of the wound.

Choice D rationale:

Collecting a tissue sample from the wound during a surgical procedure is the most accurate way to obtain a culture. However, this is not always feasible or necessary.

It is often possible to obtain an accurate culture by collecting a sample from the wound using a sterile swab. This is a less invasive procedure and can be done at the bedside.

Choice A rationale:

Directly addresses the primary goal of preventing perioperative positioning injury: The absence of redness or breakdown in the skin is the most definitive indicator that the patient has not sustained any skin or tissue damage as a result of prolonged immobilization during surgery.

Focuses on the patient outcome, not just interventions: While interventions such as padding bony prominences and assessing skin prior to surgery are important, they are means to achieve the ultimate goal of preventing skin injury. This outcome statement directly measures the success of those interventions.

Aligns with best practices for pressure injury prevention: The National Pressure Injury Advisory Panel (NPIAP) and other expert organizations emphasize the importance of setting goals that focus on maintaining skin integrity and preventing injury.

Choice B rationale:

Addresses a crucial aspect of patient care, but not directly related to positioning injury: Maintaining privacy and dignity is essential for all patients, but it does not specifically address the risk of skin breakdown from prolonged immobilization.

Not a measurable outcome for positioning injury: It is difficult to objectively assess whether a patient's privacy and dignity have been maintained, making it less suitable as an outcome statement for this particular diagnosis.

Choice C rationale:

Describes an important intervention, but not a patient outcome: Padding bony prominences is a key strategy to reduce pressure and prevent skin injury. However, it is an action taken by the nurse, not a measurable outcome that reflects the patient's status.

Does not guarantee prevention of injury: Even with appropriate padding, patients can still develop pressure injuries if other risk factors are present or if repositioning is not performed adequately.

Choice D rationale:

Represents an essential assessment step, but not a final outcome: Assessing the skin prior to surgery is important for identifying areas that are at increased risk of breakdown. However, it is a preliminary step in the prevention process, not the ultimate goal.

Does not ensure prevention of injury: Identifying at-risk areas is helpful for targeting interventions, but it does not guarantee that skin breakdown will not occur.