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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Sodium bicarbonate is used to treat metabolic acidosis, not respiratory alkalosis. It helps to neutralize excess acid in the blood, which is not the issue in respiratory alkalosis where the problem is a deficit of CO₂, not an excess of acid.
B. Placing the head between the knees might help with dizziness or lightheadedness but does not address the underlying issue of hyperventilation or help with CO₂ retention.
C. Breathing into a paper bag can help the client re-breathe exhaled CO₂, which helps to correct the imbalance caused by hyperventilation. This method assists in raising CO₂ levels in the blood, which can help normalize the pH and alleviate symptoms of respiratory alkalosis.
D. Insulin is used to manage blood glucose levels in diabetes and is not relevant to the treatment of respiratory alkalosis.
Correct Answer is C
Explanation
A. Petroleum-based products should not be used in conjunction with oxygen therapy. They are flammable and can pose a fire hazard when used near oxygen. Instead, use water-based moisturizers to prevent dryness of the lips and skin.
B. Wool and other synthetic fabrics can generate static electricity, which is a fire hazard when using oxygen
therapy. It’s safer to use cotton blankets, as they are less likely to cause static buildup.
C. Oxygen tanks should be stored upright to prevent them from falling over and to ensure the regulator and valves are properly aligned. Storing tanks upright helps maintain stability and prevents accidental damage to the equipment.
D. While the recommendation to keep oxygen tanks away from electrical sources is important, the distance may vary based on specific guidelines. It is generally advised to keep oxygen tanks at least 5-10 feet away from electrical sources and heat sources to avoid any risk of ignition or fire.
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