A post-operative patient is at risk for developing a wound infection. Which of the following nursing assessments is the highest priority to prevent this complication?
Monitoring the patient's vital signs
Assessing the patient's pain level
Inspecting the surgical incision site for redness, swelling
Assessing the patient's fluid intake and output
The Correct Answer is C
A. While important for overall patient assessment, it's not the most direct way to monitor for a wound infection.
B. Pain can indicate a wound infection, but it's not as specific as directly inspecting the wound.
C. This is the most direct way to assess for early signs of a wound infection. Redness, swelling, warmth, and drainage are classic signs of infection.
D. Important for overall patient care, but not specifically related to wound infection prevention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
desired dose / available dose) x available volume.
The desired dose is 250 mg, and the available dose is 1000 mg in 8 mL.
So, the calculation would be: (250 mg / 1000 mg) x 8 mL = 2 mL. Therefore, the nurse should administer 2 mL of hydrocortisone sodium succinate.
Correct Answer is B
Explanation
A. Lubricating the suction catheter tip with sterile saline is generally not recommended. The catheter tip is usually not lubricated before suctioning. Instead, suctioning should be performed using a dry, sterile catheter to prevent introducing any substances into the airway that could cause irritation or infection.
B. Hyperoxygenating the patient with 100% oxygen before suctioning is a crucial step. This helps to prevent hypoxia during the suctioning procedure, as suctioning can temporarily reduce the oxygen levels in the blood. By providing 100% oxygen for 30 to 60 seconds, the nurse ensures that the patient has an adequate oxygen reserve and reduces the risk of oxygen desaturation during suctioning.
C. Performing chest physiotherapy is not a routine pre-suctioning action and is generally done as part of a separate management strategy for clearing secretions. Chest physiotherapy involves techniques such as percussion, vibration, and postural drainage to help mobilize secretions from the lungs.
D. Instilling normal saline into the airway before suctioning (known as “normal saline lavage”) is not recommended. This practice can actually cause harm, such as increasing the risk of infection, causing bronchospasm, and diluting secretions which may then become more difficult to suction.
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