A nurse is caring for a client who had a percutaneous insertion of an inferior vena cava filter and was on heparin therapy before surgery.
The nurse would inspect the surgical site most closely for signs of:
Bleeding and wound dehiscence.
Wound dehiscence and evisceration.
Thrombosis and infection.
Bleeding and infection.
The Correct Answer is D
Choice A rationale:
Bleeding is a concern due to the recent surgery and heparin therapy, which can increase bleeding risk. However, wound dehiscence (wound separation) is less likely in a percutaneous insertion compared to open surgery.
Percutaneous insertion involves a smaller incision and less tissue disruption, reducing the chances of wound dehiscence.
While monitoring for bleeding is crucial, wound dehiscence may not be the most immediate concern in this specific scenario.
Choice B rationale:
Wound dehiscence and evisceration (protrusion of internal organs) are serious complications, but they are less likely to occur with percutaneous insertion compared to open surgery.
The smaller incision and minimal tissue disruption in percutaneous insertion lower the risk of these complications.
While vigilance for wound complications is essential, the priority in this case lies with bleeding and infection.
Choice C rationale:
Thrombosis (blood clot formation) is a potential complication of IVC filter placement, but it's not typically associated with the surgical site itself.
Infection is a concern for any surgical procedure, but it's not the most immediate risk in this scenario given the emphasis on bleeding and the patient's recent heparin therapy.
Choice D rationale:
Bleeding:
Heparin therapy, a blood thinner, increases the risk of bleeding.
The surgical site is a potential area for bleeding, as it involves disruption of blood vessels.
Meticulous monitoring for bleeding is essential to ensure prompt intervention if it occurs.
Infection:
Any surgical procedure carries a risk of infection.
The surgical site is a potential entry point for bacteria.
Close observation for signs of infection, such as redness, swelling, warmth, or drainage, is crucial for early detection and treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is E
Explanation
Choice A rationale:
While aspirin can help improve heart function in certain cases, such as by reducing inflammation, it's not accurate to say it directly restores normal heart function. This statement oversimplifies aspirin's mechanism of action and could mislead the client.
It's essential to emphasize aspirin's role in preventing clots, which is the primary reason for its use in coronary artery disease.
Choice B rationale:
Aspirin does not affect the oxygen-carrying capacity of blood. This function is primarily carried out by hemoglobin in red blood cells.
Stating that aspirin increases oxygen-carrying capacity could create misunderstandings about its role in coronary artery disease.
Choice C rationale:
Aspirin does not directly make blood penetrate the heart more freely. Its action primarily involves preventing blood clots from forming within blood vessels.
This statement could lead to a misconception about aspirin's mechanism of action, potentially affecting adherence to treatment.
Choice D rationale:
This is the most accurate and comprehensive response. It directly addresses the client's question and highlights the primary reason for daily aspirin use in coronary artery disease.
Aspirin inhibits platelet aggregation, reducing the risk of blood clots that can obstruct coronary arteries and trigger heart attacks or chest pain.
By preventing these blockages, aspirin can help prevent future cardiovascular events and improve the client's overall health outcomes.
Correct Answer is B
Explanation
correct answer is Choice B.
Choice B rationale:
Orthostatic hypotension is a significant drop in blood pressure that occurs when a person stands up from a lying or sitting position. It's characterized by a decrease in systolic blood pressure of at least 20 mmHg or a decrease in diastolic blood pressure of at least 10 mmHg within 3 minutes of standing.
The client's assessment data clearly demonstrates orthostatic hypotension, with a systolic blood pressure drop of 23 mmHg and a diastolic drop of 13 mmHg upon standing.
Orthostatic hypotension is a major risk factor for falls, especially in older adults. This is because the sudden decrease in blood pressure can lead to lightheadedness, dizziness, blurred vision, weakness, and even fainting.
Falls in older adults can result in serious injuries, such as fractures, head trauma, and even death. Therefore, it's crucial to identify and address orthostatic hypotension to prevent falls and their associated complications.
Rationales for other choices:
Choice A: Ineffective breathing pattern is not directly related to orthostatic hypotension. While hypotension can cause shortness of breath in some cases, it's not the primary concern in this scenario.
Choice C: Ineffective role performance can be a consequence of frequent falls, but it's not the most immediate or pressing nursing diagnosis in this case.
Choice D: Risk for imbalanced fluid balance is a potential concern in some cases of orthostatic hypotension, but it's not the most likely diagnosis based on the client's assessment data.
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