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 B
Explanation
A. Abdominal pain is not a direct manifestation of respiratory acidosis. However, it may be associated with other conditions or complications but is not a primary indicator of respiratory acidosis.
B. Lethargy or drowsiness is a common symptom of respiratory acidosis. The increased CO₂ levels lead to an acidic environment that can affect brain function, resulting in decreased alertness, confusion, or drowsiness.
C. Numbness or tingling of the fingers is more commonly associated with respiratory alkalosis, which is characterized by a decreased level of CO₂ and increased blood pH. This condition can cause peripheral numbness and tingling due to altered blood pH affecting nerve function.
D. Dry skin is not a direct manifestation of respiratory acidosis. While it might be a sign of dehydration or other systemic issues, it is not specifically linked to respiratory acidosis.
Correct Answer is ["C","E"]
Explanation
A. Explaining the risks and benefits of the procedure is generally the responsibility of the surgeon or the healthcare provider who will perform the procedure. They are in the best position to provide detailed and specific information about the procedure, including potential complications and benefits.
B. Similar to explaining the risks and benefits, discussing alternatives is usually done by the surgeon or the provider. The nurse should ensure that the client is aware that alternatives are available and that this information has been provided by the appropriate medical professional.
C. It is the responsibility of the surgeon or the healthcare provider to obtain informed consent. However, the nurse should confirm that the consent process has been completed. This means ensuring that the consent form is signed and that the client has been properly informed. While the nurse does not obtain consent, they verify that it has been done correctly.
D. Describing the consequences of not undergoing the surgery is part of the informed consent process and is generally the responsibility of the surgeon. The nurse should ensure that this information has been communicated to the client by the appropriate provider.
E. The nurse often acts as a witness to the client’s signature on the consent form. This involves confirming that the client has signed the form voluntarily and after being fully informed. The nurse’s role in this process is to ensure the proper documentation and verification that the consent has been given.
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