The nurse identifies which of the following as one of the primary nursing interventions for preventing surgical site infection?

Having the patient splint their incision site when coughing and deep breathing

Offering around the clock pain medication the immediate post operative phase

Administering prescribed pre-operative antibiotics within 30-60 minutes of surgery.

Performing the first dressing change on a new surgical site in the post operative setting

Answer and Explanation

The Correct Answer is C

A. Having the patient splint their incision site when coughing and deep breathing:
While splinting the incision site can help alleviate pain and prevent strain on the surgical wound during coughing and deep breathing, it is not a primary intervention for preventing surgical site infection. Infection prevention is more directly related to sterile technique, antibiotic prophylaxis, and maintaining a clean environment around the wound. Splinting can support postoperative recovery, but it does not directly prevent infection.

B. Offering around the clock pain medication in the immediate post-operative phase:
Providing pain medication is important for patient comfort and to facilitate early mobilization after surgery. However, pain management does not directly prevent surgical site infections. The focus for infection prevention lies in maintaining sterility, administering antibiotics as prescribed, and appropriate wound care rather than pain control alone.

C. Administering prescribed pre-operative antibiotics within 30-60 minutes of surgery:
The administration of prophylactic antibiotics before surgery, typically within 30-60 minutes of the incision, is a primary intervention for preventing surgical site infections (SSIs). This timing ensures that the antibiotics are at therapeutic levels in the bloodstream when the surgical procedure begins, reducing the risk of introducing bacteria into the surgical site. This is a well-established guideline for infection prevention in surgical settings.

D. Performing the first dressing change on a new surgical site in the postoperative setting:
The first dressing change should generally be done by a healthcare professional using sterile technique. However, the timing and handling of the first dressing change are more related to wound care practices rather than a primary strategy for preventing infection. Infection prevention primarily involves proper antibiotic prophylaxis, maintaining a sterile field, and managing the surgical site during the early post-operative period. The first dressing change, while important for wound healing, is not the most immediate or primary intervention for preventing surgical site infection.

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Correct Answer is C

Explanation

A) "HDL cholesterol 60 mg/dL":
This is not a risk factor. High-density lipoprotein (HDL) is often referred to as "good cholesterol" because it helps remove excess cholesterol from the bloodstream, lowering the risk of atherosclerosis and cardiovascular disease. An HDL level of 60 mg/dL is considered protective against cardiovascular disease, as higher levels of HDL are associated with a lower risk of heart disease.

B) "Total cholesterol 210 mg/dL":
This is not a significant risk factor on its own. While total cholesterol above 200 mg/dL is a general indicator for cardiovascular risk, it is not as important as the breakdown of individual lipid components (HDL, LDL). A total cholesterol of 210 mg/dL is only slightly above the ideal less than 200 mg/dL, and on its own, it is not a strong indicator of increased cardiovascular risk without considering other factors like LDL and HDL levels.

C) "LDL cholesterol 110 mg/dL":
. Low-density lipoprotein (LDL) is known as "bad cholesterol" because it can lead to the buildup of plaque in the arteries, increasing the risk for atherosclerosis, heart disease, and stroke. An LDL level of 110 mg/dL is considered to be above optimal. For individuals at risk for cardiovascular disease, the target LDL cholesterol level is usually less than 100 mg/dL, and for those with high risk, it may be less than 70 mg/dL. Therefore, this level of LDL cholesterol places the client at increased risk for cardiovascular disease.

D) "Hgb A1C 5.3%":
This is not a risk factor. An Hgb A1C of 5.3% is within the normal range for glycemic control. The American Diabetes Association defines normal A1C as below 5.7%. A1C levels between 5.7% and 6.4% are considered pre-diabetes, and a level of 6.5% or higher indicates diabetes. A normal A1C level indicates no significant elevated blood glucose, which would be a risk factor for cardiovascular disease.

A. Respiratory acidosis B. Metabolic acidosis C. Respiratory alkalosis D. Metabolic alkalosis

Correct Answer is C

Explanation

A. Respiratory acidosis:
Respiratory acidosis is characterized by an increased CO2 level (above 45 mmHg) due to hypoventilation or impaired gas exchange, leading to a decrease in pH (below 7.35). In this case, the CO2 level is 25 mmHg, which is lower than normal and suggests a loss of CO2, not an accumulation. Therefore, respiratory acidosis is not the correct interpretation of these ABG results.
B. Metabolic acidosis:
Metabolic acidosis occurs when the pH drops below 7.35 due to conditions like kidney failure, diarrhea, or diabetic ketoacidosis. This would typically be accompanied by a low bicarbonate (HCO3-) level (less than 22 mEq/L). However, in this case, the pH is 7.52 (alkalotic), and the HCO3- level is 24 mEq/L, which is within the normal range. Thus, metabolic acidosis is not the correct interpretation.

C. Respiratory alkalosis:
Respiratory alkalosis is characterized by a decrease in CO2 (less than 35 mmHg) due to hyperventilation, which causes an increase in pH (above 7.45). In this case, the pH is 7.52 (alkalotic), and the CO2 is 25 mmHg, which is lower than the normal range (35–45 mmHg). The bicarbonate (HCO3-) level is 24 mEq/L, which is normal and compensatory. This matches the pattern of respiratory alkalosis, where the body compensates with a normal bicarbonate level as CO2 decreases.

D. Metabolic alkalosis:
Metabolic alkalosis occurs when the pH rises above 7.45, often due to excessive vomiting, diuretic use, or antacid overuse, leading to an increase in bicarbonate (HCO3-) levels. While the pH is 7.52, indicating alkalosis, the bicarbonate (HCO3-) level is 24 mEq/L, which is within the normal range for bicarbonate. In metabolic alkalosis, you would typically see an elevated HCO3- level, which is not the case here. Therefore, metabolic alkalosis is not the correct interpretation of these ABG results.

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The nurse identifies which of the following as one of the primary nursing interventions for preventing surgical site infection?

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Naxlex Comprehensive Predictor Exams

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