What Nursing Diagnosis would be a priority for a client who has had a large surgical wound from recent colon surgery, the client is obese, and the client is taking corticosteroid medications?
Anxiety.
Self-care Deficit.
Risk for Infection.
Risk for Imbalanced Nutrition.
The Correct Answer is C
Choice A rationale:
Anxiety is a valid concern for any client undergoing surgery, but it is not the priority nursing diagnosis in this case. The client's risk for infection is more pressing due to the following factors:
Large surgical wound: Wounds provide a potential entry point for pathogens.
Obesity: Excess adipose tissue can impair wound healing and increase the risk of infection.
Corticosteroid medications: These medications suppress the immune system, making it more difficult for the body to fight off infection.
Choice B rationale:
Self-care Deficit may be a concern if the client has difficulty caring for the surgical wound or maintaining hygiene due to obesity. However, it is not the priority diagnosis in this case. The focus should be on preventing infection, which would also help to address any self-care deficits.
Choice D rationale:
Risk for Imbalanced Nutrition is a relevant diagnosis for a client who has had colon surgery, as they may experience changes in appetite, digestion, or absorption of nutrients. However, it is not the priority diagnosis in this scenario. Preventing infection is crucial to ensure proper wound healing and overall recovery.
Choice C rationale:
Risk for Infection is the priority nursing diagnosis for this client due to the following risk factors: Large surgical wound: The wound provides a potential entry point for bacteria and other pathogens.
Obesity: Excess adipose tissue can impair wound healing by reducing blood flow to the area and increasing the risk of wound dehiscence (separation of wound edges). This can create a favorable environment for bacterial growth.
Corticosteroid medications: These medications suppress the immune system, making it more difficult for the body to fight off infection.
Nursing interventions to address Risk for Infection:
Assess the wound regularly for signs of infection, such as redness, swelling, warmth, pain, or purulent drainage. Implement strict aseptic technique when caring for the wound.
Teach the client about proper wound care and hygiene practices.
Monitor the client for signs of systemic infection, such as fever, chills, or malaise. Administer antibiotics as prescribed.
Encourage adequate nutrition and hydration to support wound healing.
Collaborate with the healthcare team to manage the client's risk factors for infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
While comparing intra-operative data to post-operative outcomes can be valuable for research and quality improvement purposes, it's not the primary purpose of immediate post-operative assessments in the PACU.
The focus in the PACU is on the patient's immediate well-being and stabilization, not on long-term data analysis.
Choice B rationale:
Preventing complications:
Early detection of potential complications is crucial for timely intervention and prevention of adverse events.
Assessments identify changes in vital signs, respiratory status, pain levels, level of consciousness, surgical site integrity, and other indicators of potential complications.
Monitoring and stabilizing the patient:
Nurses closely monitor patients' physiological responses to anesthesia and surgery, ensuring vital signs remain within acceptable ranges and managing any deviations.
They assess pain levels and administer analgesics as needed, promote respiratory function, maintain fluid and electrolyte balance, and address any other post-operative concerns.
Choice C rationale:
While cardiovascular data is indeed crucial in the PACU, it's not the sole focus of assessments.
Nurses assess a comprehensive range of body systems to ensure overall patient stability and recovery.
Choice D rationale:
Determining recovery time is important, but it's secondary to ensuring patient safety and stability.
Assessments prioritize identifying and addressing potential complications, promoting recovery, and ensuring a safe transition from the PACU.
Correct Answer is D
Explanation
Choice A rationale:
While urinary tract infections (UTIs) are a potential risk with furosemide use, they are not the most immediate or anticipated effect following initiation of the medication.
UTIs can occur due to changes in urinary flow and potential catheter use.
However, furosemide's primary action is to increase urine output, which would not directly lead to a higher risk of UTIs at the onset of treatment.
Choice B rationale:
Concentrated dark urine is typically associated with dehydration or conditions that cause the kidneys to conserve water, such as kidney disease or severe fluid loss.
Furosemide, on the other hand, is a diuretic that promotes water loss through the urine, leading to more dilute urine.
Choice C rationale:
Transient incontinence can occur with furosemide due to the rapid increase in urine production, but it is not the most predictable or anticipated effect.
Increased urine production is expected, but transient incontinence may or may not occur in all patients.
Choice D rationale:
This is the most accurate and anticipated response.
Furosemide is a loop diuretic that works by inhibiting the reabsorption of sodium and chloride in the loop of Henle in the kidneys.
This leads to a significant increase in urine output, often within a few hours of administration. The urine produced is typically dilute and light-colored, as it contains a higher concentration of water and electrolytes. This is the intended effect of furosemide, as it helps to reduce fluid overload and edema.
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