A patient is incontinent on the first day after surgery. This is a risk factor for the development of skin breakdown and infection primarily because:
The moisture creates an environment suitable for the growth of microorganisms in a wound.
Greater pressure is exerted by a wet bed.
Shearing is more likely from wet sheets.
The patient has to be repositioned for the bed to be changed.
The Correct Answer is A
Choice A rationale
Moisture from incontinence can compromise skin integrity and create a favorable environment for bacterial growth, increasing the risk of infection and skin breakdown.
Choice B rationale
While a wet bed may be uncomfortable, it does not exert greater pressure that would lead to skin breakdown or infection.
Choice C rationale
Shearing can occur from moving a patient on any surface; however, wet sheets do not inherently increase the likelihood of shearing.
Choice D rationale
Repositioning the patient is necessary for comfort and to prevent pressure ulcers, but it is not a direct cause of skin breakdown or infection due to incontinence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A:
This is the correct choice. The Jackson-Pratt drain incorporates a flexible bulb that aspirates drainage from the wound by self-suction. When the reservoir is half full, the suction pressure is diminished. Thus it is appropriate to empty it and record the amount of drainage you discard.
Choice B:
While it's important to keep the surgeon informed about the patient's condition, in this case, the purpose of the Jackson-Pratt drain is to aspirate drainage, such as excess blood, from the wound. Many factors are involved in determining what an acceptable amount of drainage is; however, excessive blood loss that must be reported is likely to affect the patient's vital signs.
Choice C:
The surgeon determines when to remove the drain, and in most cases, a patent and functioning drain remains in place for a few days.
Choice D:
Leaving the reservoir half full until the end of the shift is not recommended. The suction pressure is diminished when the reservoir is half full, which could affect the drain's effectiveness.
Correct Answer is A
Explanation
Choice A rationale
A pinkish-red center and a bumpy appearance in a wound are signs of granulation tissue formation, which is indicative of the healing process beginning.
Choice B rationale
Suppuration refers to the production of pus. Without additional information indicating pus or infection, the description provided does not suggest suppuration.
Choice C rationale
Becoming infected would typically involve signs such as increased pain, redness, swelling, warmth, and possibly pus, which are not described in the scenario.
Choice D rationale
Debridement is the removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue. The description given does not indicate the presence of such tissue.
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