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Exhibits

Data is evaluated to determine possible condition and appropriate interventions. Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

Answer and Explanation

The Correct Answer is []

Condition:

Postoperative infection

2 Actions:

Administer prescribed antibiotics.
Culture wound drainage.

2 Parameters:

Temperature.
White blood cell count.

Rationale for correct condition:

A postoperative infection is the most likely condition because the patient has elevated white blood cell count (11,000/mm³) and a slightly elevated temperature (99.8°F). These findings suggest a systemic inflammatory response, potentially from infection. The presence of a recent surgical wound increases the risk of bacterial contamination. The absence of redness or drainage does not rule out deeper tissue infection. The patient’s symptoms align with early signs of an infectious process.

Rationale for the two correct actions:

Administer prescribed antibiotics: Antibiotics target potential bacterial infection, which is critical to prevent further complications such as systemic infection or sepsis.
Culture wound drainage: This identifies the causative organism and guides appropriate antibiotic therapy. Even if the wound appears clean externally, culturing can confirm or rule out deeper infection.

Rationale for parameters to monitor:

Temperature: Monitoring temperature helps identify trends in fever, a common sign of infection progression or resolution.
White blood cell count: Elevated levels are a marker of infection or inflammation. Monitoring changes in WBC count can indicate if treatment is effective.

Rationale for incorrect conditions:

Surgical rash: A rash is not indicated in the notes, and the elevated WBC count and temperature do not suggest a dermatologic issue.
Contractures: No evidence suggests reduced mobility or positioning problems causing contractures.
Deep vein thrombosis (DVT): The client’s normal vital signs and lack of redness or swelling in the residual limb make DVT less likely.

Rationale for incorrect actions to take:

Request NPO prescription: There is no evidence of gastrointestinal issues or surgery requiring this intervention.
Elevate residual limb to reduce swelling: While useful in managing swelling, there is no current sign of significant limb edema requiring elevation.
Educate on incentive spirometer use: This is preventive for respiratory complications but unrelated to infection management.

Rationale for incorrect parameters to monitor:

Adherence to activity prescription: While important for recovery, it does not directly address infection.
Residual limb redness or swelling: Although relevant to infection, there is no current evidence of redness or swelling in the notes.
Pain intensity and characteristics: Pain is already being managed with morphine, and its current level (5/10) does not directly indicate infection.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Placing the chin down and tilting the head for dysphagia (difficulty swallowing) during meals is not directly related to managing mucositis. While it may help with swallowing difficulties, it does not address the inflammation and pain caused by mucositis.

Choice B reason: Normal saline mouth rinses as swish and spit after meals and bedtime is an effective intervention for managing mucositis. Rinsing with saline helps to keep the mouth clean, reduce bacterial load, and soothe inflamed tissues. It can also help to remove food particles and debris, reducing the risk of infection and promoting healing. Saline rinses are gentle and do not contain irritating ingredients, making them ideal for sensitive oral tissues affected by mucositis.

Choice C reason: Eating high caloric meals to prevent weight loss is important for overall nutrition, especially for clients undergoing cancer treatment. However, it does not specifically address the management of mucositis. High caloric meals alone will not alleviate the pain, inflammation, and ulceration associated with mucositis. Clients with mucositis often have difficulty eating due to pain, so focusing on soothing and healing the oral tissues is a priority before addressing caloric intake.

Choice D reason: Using a commercial mouthwash for xerostomia (dry mouth) is not recommended for managing mucositis. Many commercial mouthwashes contain alcohol and other harsh ingredients that can further irritate the already inflamed mucous membranes. It is better to use a gentle and soothing rinse, such as saline, to manage mucositis symptoms and promote healing of the oral tissues.

A. Review written and verbal instructions for a reduced sodium diet. B. Teach strategies for aseptic administration of the eye drops. C. Describe how the use of the eye drops will help improve peripheral vision. D. Teach to apply pressure over the inner eye corner after eye drops. E. Explain the need to continue eye drops for the rest of their life.

Correct Answer is ["B","D","E"]

Explanation

Choice A reason: Reviewing written and verbal instructions for a reduced sodium diet is not directly related to the management of primary open-angle glaucoma (POAG). While a healthy diet can contribute to overall well-being, dietary sodium does not have a significant impact on intraocular pressure or glaucoma management. Therefore, this intervention does not directly address the client's primary condition of POAG.

Choice B reason: Teaching strategies for aseptic administration of the eye drops is a critical intervention for clients with POAG. Proper administration of ophthalmic drops is essential to avoid contamination and infection. Aseptic techniques include washing hands before administering the drops, avoiding touching the dropper tip to any surface (including the eye), and ensuring that the dropper cap is replaced tightly after use. These measures help maintain the sterility of the medication and prevent complications such as eye infections, which can exacerbate the client's condition.

Choice C reason: Describing how the use of the eye drops will help improve peripheral vision is not entirely accurate in the context of POAG. The primary goal of ophthalmic drops for POAG is to lower intraocular pressure and prevent further damage to the optic nerve, thereby preserving the remaining vision. These drops do not typically improve peripheral vision that has already been lost. Educating the client with accurate information about the purpose and benefits of the drops helps set realistic expectations and encourages adherence to the treatment regimen.

Choice D reason: Teaching the client to apply pressure over the inner eye corner (punctal occlusion) after administering eye drops is an important intervention. Punctal occlusion helps prevent the medication from draining into the tear duct and being absorbed systemically. This technique increases the contact time of the medication with the eye, enhancing its effectiveness and reducing potential systemic side effects. Clients should be instructed to gently press the inner corner of the eye for a few minutes after instilling the drops to ensure maximum benefit.

Choice E reason: Explaining the need to continue eye drops for the rest of their life is essential for clients with POAG. Glaucoma is a chronic condition that requires lifelong management to control intraocular pressure and prevent progression of the disease. Discontinuing the medication can lead to elevated intraocular pressures and irreversible vision loss. Clients should understand the importance of adherence to their prescribed treatment regimen and the lifelong commitment to managing their condition to preserve their vision and quality of life.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with oral cancer is receiving radiotherapy (RT) prior to surgery. Which intervention should the nurse teach the client to implement in managing mucositis related to RT?

Correct Answer is B

Explanation

Correct Answer is ["B","D","E"]

Explanation

Exhibits The nurse has implemented additional needed actions. Indicate the assessment data which indicate the interventions were successful and which assessment data provide no indication that the interventions were successful. Each column must have at least one answer selected.

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