What is the priority outcome for a patient with the nursing diagnosis of fluid volume deficit related to ongoing postoperative bleeding?

The patient’s temperature will remain within normal limits.

The patient’s surgical incision will remain intact with sutures.

The patient will verbalize measures to reduce fluid volume loss.

The patient’s urine output will be at least 30 mL/hour.

Answer and Explanation

The Correct Answer is D

Rationale for Choice A:

While maintaining normal body temperature is important for overall health, it's not the most immediate priority in a patient with fluid volume deficit due to ongoing bleeding. Fluid volume status takes precedence over temperature regulation in this context.

Hypovolemia can lead to hypothermia, but addressing the fluid deficit directly will also help stabilize temperature.

Focusing solely on temperature could delay crucial interventions to address the fluid loss and potentially worsen the patient's condition.

Rationale for Choice B:

An intact surgical incision is essential for proper wound healing and prevention of infection. However, in the context of active bleeding, it's not the priority outcome.

Maintaining adequate fluid volume is crucial to ensure perfusion of tissues, delivery of oxygen and nutrients, and proper organ function—all of which take precedence over incision integrity in this acute situation.

Addressing the fluid deficit will indirectly support wound healing by promoting tissue perfusion and reducing the risk of complications.

Rationale for Choice C:

Patient education is important, but it's not the most immediate priority in a patient with active bleeding and fluid volume deficit.

The patient's ability to comprehend and implement measures to reduce fluid loss may be compromised due to the hypovolemic state and potential cognitive effects.

Focusing on patient education at this stage could delay essential interventions to address the fluid loss and potentially worsen the patient's condition.

Rationale for Choice D:

Urine output is a sensitive and reliable indicator of renal perfusion and overall fluid status. In a patient with fluid volume deficit, maintaining a urine output of at least 30 mL/hour is a key indicator that the kidneys are receiving adequate blood flow and that fluid volume is being restored.

This outcome directly addresses the fluid deficit and serves as a measurable goal for fluid replacement therapy.

It takes priority over other choices because it directly reflects the patient's fluid status and the effectiveness of interventions to address the bleeding and fluid loss.

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Correct Answer is C

Explanation

Choice A rationale:

Burning dried herbs is a form of traditional medicine, not allopathic medicine.

Traditional medicine encompasses a wide range of practices and therapies that have been used for centuries across different cultures.

It often relies on natural substances and processes, such as herbs, acupuncture, and massage, to promote healing and well- being.

While traditional medicine can offer valuable benefits, it's important to note that it's not always based on scientific evidence and its efficacy can vary depending on the specific practice and condition being treated.

Choice B rationale:

Tai chi exercises are a form of complementary and alternative medicine (CAM), not allopathic medicine.

CAM encompasses a diverse group of therapies that are not considered part of mainstream conventional medicine. Tai chi is a mind-body practice that involves gentle, flowing movements and deep breathing.

It has been shown to offer a range of health benefits, including reducing stress, improving balance, and easing pain.

However, it's important to note that tai chi is not a cure-all and should not be used as a substitute for conventional medical care when necessary.

Choice C rationale:

Prescription of antibiotic medication is a hallmark of allopathic medicine.

Allopathic medicine, also known as conventional or Western medicine, is based on the scientific understanding of the body and disease.

It focuses on diagnosing and treating specific diseases or conditions using medications, surgery, or other interventions that have been proven effective through rigorous scientific research.

Antibiotics are a type of medication that specifically targets and kills bacteria.

They are essential for treating bacterial infections, which can cause a wide range of illnesses, from minor skin infections to life- threatening pneumonia.

Choice D rationale:

Manipulation of the spine, also known as chiropractic care, is a form of CAM, not allopathic medicine. Chiropractic care focuses on the musculoskeletal system, particularly the spine.

Chiropractors use manual adjustments to the spine to relieve pain, improve range of motion, and restore function.

While some studies have shown that chiropractic care can be effective for certain conditions, such as lower back pain, it's important to note that it's not a cure-all and should not be used as a substitute for conventional medical care when necessary.

A. The nurse should aspirate immediately prior to injecting the medication. B. The nurse should gently massage the injection site immediately afterward. C. The nurse should draw up the medication into a 1-mL syringe with a 32-gauge needle. D. The nurse should inject the medication into the soft tissue of the patient’s abdomen.

Correct Answer is D

Explanation

Choice A rationale:

Aspiration prior to injection of enoxaparin is not recommended. Key reasons for this contraindication include:

Absence of Large Blood Vessels in Subcutaneous Tissue: Enoxaparin is administered subcutaneously, targeting the fatty tissue layer beneath the skin. This tissue generally lacks large blood vessels, significantly reducing the risk of accidental intravascular injection. Aspiration, traditionally intended to prevent such occurrences, becomes unnecessary in this context.

Potential for Hematoma Formation: The act of aspiration itself can create a vacuum within the subcutaneous tissue, leading to trauma and bleeding at the injection site. This can result in hematoma formation, causing discomfort and potential interference with medication absorption.

No Evidence of Benefit: Research studies have not demonstrated any clear advantages of aspiration when administering subcutaneous enoxaparin injections. In fact, some studies have suggested a potential increase in bruising and bleeding associated with aspiration.

Manufacturer Guidelines: Enoxaparin manufacturers explicitly advise against aspiration in their product instructions, aligning with current evidence-based practices.

Choice B rationale:

Massaging the injection site after administering enoxaparin is also not recommended.

Rationale for this contraindication:

Accelerated Absorption: Massaging can increase local blood flow, potentially accelerating the absorption of enoxaparin. This could lead to higher-than-intended drug levels in the bloodstream, increasing the risk of bleeding complications.

Discomfort and Hematoma Risk: Similar to aspiration, massage can create mechanical stress on the injection site, potentially causing bruising, discomfort, or hematoma formation.

Choice C rationale:

While a 1-mL syringe with a 32-gauge needle is a suitable option for subcutaneous injections, it's not the only correct choice. Considerations for syringe and needle selection:

Needle Length: The needle should be short enough to ensure subcutaneous administration, typically ranging from 5/8 to 1 inch in length.

Syringe Size: The syringe size should accommodate the volume of medication being administered, providing clear visibility of the dose.

Patient Comfort: Smaller-gauge needles (like 32-gauge) are often preferred for subcutaneous injections as they tend to cause less discomfort. However, other factors, such as medication viscosity and patient preferences, may influence needle selection.

Choice D rationale:

The abdomen is the preferred injection site for enoxaparin due to several reasons:

Abundant Subcutaneous Tissue: The abdomen generally has a thicker layer of subcutaneous tissue, providing ample space for medication absorption and reducing the risk of intramuscular injection.

Ease of Access: The abdomen is often easily accessible for self-injection or administration by a caregiver, promoting patient comfort and convenience.

Reduced Pain: Subcutaneous injections in the abdomen are typically less painful compared to other potential sites like the arms or thighs.

Additional considerations for enoxaparin administration:

Rotate Injection Sites: To prevent tissue damage and promote consistent absorption, it's crucial to rotate injection sites within the recommended areas (abdomen, thighs, upper buttocks).

Monitor for Adverse Effects: Observe for any signs of bleeding, bruising, or allergic reactions following enoxaparin administration.

Adhere to Storage Guidelines: Store enoxaparin at room temperature and protect it from light to ensure its efficacy.

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What is the priority outcome for a patient with the nursing diagnosis of fluid volume deficit related to ongoing postoperative bleeding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

For the Nursing Exam #3 (Winter 2023), which of the following is an example of allopathic treatment?

Correct Answer is C

Explanation

The nurse is preparing to administer 40 mg of enoxaparin subcutaneously to a patient. Which of the following techniques should the nurse use?

Correct Answer is D

Explanation

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