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

Answer and Explanation

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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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.

A. Increase sodium intake. B. Infuse hypotonic IV fluids. C. Administer sodium polystyrene sulfonate. D. Implement a fluid restriction.

Correct Answer is B

Explanation

A. Increasing sodium intake would exacerbate hypernatremia, not correct it. Hypernatremia is characterized by an excess of sodium in the blood, so the goal of treatment is to lower sodium levels, not increase them.
B. Infusing hypotonic IV fluids, such as 0.45% NaCl or D5W (5% dextrose in water), helps to dilute the high sodium concentration in the blood and can assist in correcting hypernatremia. Hypotonic fluids move water into cells and help balance the sodium levels by promoting hydration and lowering the sodium concentration.
C. Sodium polystyrene sulfonate (Kayexalate) is used to treat hyperkalemia (elevated potassium levels), not hypernatremia. It works by exchanging potassium for sodium in the gastrointestinal tract and would not address hypernatremia.
D. Implementing a fluid restriction is generally not the best approach for treating hypernatremia. In fact, fluid restriction could worsen hypernatremia by limiting the client's fluid intake and not addressing the sodium imbalance. The primary goal in hypernatremia is usually to rehydrate the patient with appropriate fluids.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["2"]

Explanation

A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse include in the plan of care?

Correct Answer is B

Explanation

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