A nurse is caring for a patient who has a surgical wound. Which of the following factors places the patient at risk for dehiscence? Select all that apply.
Poor nutritional status
Medication administration
Obesity
Nonadherence
Increased metabolic rate
The Correct Answer is A
Choice A reason: Poor nutritional status can impair wound healing and increase the risk of wound dehiscence.
Choice B reason: Medication administration is too vague to determine a risk for dehiscence without specifying the type of medication.
Choice C reason: Obesity can increase the risk of dehiscence due to the strain on the wound from excess tissue.
Choice D reason: Nonadherence could contribute to dehiscence if it refers to not following postoperative care instructions, but it is not specific enough in this context.
Choice E reason: An increased metabolic rate can lead to higher demands on the body's healing process, potentially affecting wound integrity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Metabolic acidosis is characterized by a low pH and a normal or low HCO3. In this case, the pH is 7.25, which is below the normal range of 7.35-7.45, and the HCO3 is 22, which is at the lower end of the normal range of 22-26 mEq/L, indicating metabolic acidosis.
Choice B reason: Respiratory acidosis is characterized by a high CO2 level. However, in this scenario, the CO2 is 40, which is within the normal range of 35-45 mmHg, ruling out respiratory acidosis.
Choice C reason: Metabolic alkalosis would present with a high pH and a high HCO3 level. Since the pH is low, metabolic alkalosis is not the correct answer.
Choice D reason: Respiratory alkalosis is characterized by a low CO2 level and a high pH. Given that the CO2 is normal and the pH is low, respiratory alkalosis is not the condition indicated by these ABG results.
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Correct Answer is B
Explanation
Choice A reason: While bed rest may be required immediately after surgery, patients are typically encouraged to mobilize as soon as possible to prevent complications.
Choice B reason: Using a special soap the evening before surgery is a common preoperative instruction to reduce the risk of infection.
Choice C reason: A CPM machine is often used after hip replacement surgery to promote movement and prevent joint stiffness.
Choice D reason: A heating pad is generally not recommended on the operative site immediately after surgery due to the risk of burns and bleeding.
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The correct answer is choice B. “You will use a special soap to shower with the evening before your surgery.” Choice A rationale: Remaining in bed for at least the first 24 hours is not typically recommended. Early mobilization is encouraged to prevent complications such as blood clots and to promote faster recovery. Choice B rationale: Using a special soap to shower with the evening before surgery is a common preoperative instruction. This helps reduce the risk of infection by decreasing the number of bacteria on the skin. Choice C rationale: Continuous passive motion (CPM) machines are generally used for knee replacement surgeries, not hip replacements. They help in maintaining joint mobility and preventing stiffness, but are not standard for hip surgeries. Choice D rationale: Using a heating pad on the operative site is not recommended as it can increase swelling and the risk of burns. Cold therapy is usually preferred to reduce pain and inflammation postoperatively. |
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