A nurse is caring for a patient who will be undergoing a surgical procedure that will take 7 to 8 hours to complete.
What is the appropriate outcome for the diagnosis of perioperative positioning injury related to prolonged immobilization?
The patient’s skin will be free of redness or breakdown when surgery is complete.
The patient’s privacy and dignity will be maintained throughout the procedure.
The patient’s bony prominences will be padded with pressure-reducing cushions.
The patient’s skin will be assessed prior to surgery to identify areas at risk.
The Correct Answer is A
Choice A rationale:
Directly addresses the primary goal of preventing perioperative positioning injury: The absence of redness or breakdown in the skin is the most definitive indicator that the patient has not sustained any skin or tissue damage as a result of prolonged immobilization during surgery.
Focuses on the patient outcome, not just interventions: While interventions such as padding bony prominences and assessing skin prior to surgery are important, they are means to achieve the ultimate goal of preventing skin injury. This outcome statement directly measures the success of those interventions.
Aligns with best practices for pressure injury prevention: The National Pressure Injury Advisory Panel (NPIAP) and other expert organizations emphasize the importance of setting goals that focus on maintaining skin integrity and preventing injury.
Choice B rationale:
Addresses a crucial aspect of patient care, but not directly related to positioning injury: Maintaining privacy and dignity is essential for all patients, but it does not specifically address the risk of skin breakdown from prolonged immobilization.
Not a measurable outcome for positioning injury: It is difficult to objectively assess whether a patient's privacy and dignity have been maintained, making it less suitable as an outcome statement for this particular diagnosis.
Choice C rationale:
Describes an important intervention, but not a patient outcome: Padding bony prominences is a key strategy to reduce pressure and prevent skin injury. However, it is an action taken by the nurse, not a measurable outcome that reflects the patient's status.
Does not guarantee prevention of injury: Even with appropriate padding, patients can still develop pressure injuries if other risk factors are present or if repositioning is not performed adequately.
Choice D rationale:
Represents an essential assessment step, but not a final outcome: Assessing the skin prior to surgery is important for identifying areas that are at increased risk of breakdown. However, it is a preliminary step in the prevention process, not the ultimate goal.
Does not ensure prevention of injury: Identifying at-risk areas is helpful for targeting interventions, but it does not guarantee that skin breakdown will not occur.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Debridement refers to the removal of dead, damaged, or infected tissue to promote healing. It is not a term used to describe skin breakdown caused by moisture.
Choice B rationale:
Evisceration is the protrusion of internal organs through a wound or surgical incision. It is not relevant to the condition of perineal skin breakdown due to wetness.
Choice D rationale:
Dehiscence is the separation of a surgical wound. It is not applicable in this case, as there is no mention of a surgical wound.
Choice C rationale:
Maceration is a term used to describe skin that has become softened and broken down due to prolonged exposure to moisture. This is the most accurate term to describe the condition of perineal skin breakdown after sitting in wet underclothes for many hours.
Key features of maceration:
Skin softening: The skin becomes white and wrinkled, resembling a prune.
Epidermal loss: The outer layer of skin (epidermis) may slough off, leaving the underlying tissue exposed. Redness: The affected area may become red and inflamed.
Pain or tenderness: The area may be painful or tender to the touch.
Increased risk of infection: Macerated skin is more susceptible to infection due to the breakdown of the skin barrier. Causes of maceration:
Prolonged exposure to moisture: This can include sweat, urine, feces, wound drainage, or excessive bathing. Friction: Rubbing or chafing of the skin can also contribute to maceration.
Impaired circulation: Poor blood flow to the area can make it more vulnerable to maceration. Prevention of maceration:
Keep skin clean and dry: This is the most important step in preventing maceration. Change wet or soiled clothing or dressings promptly.
Apply barrier creams or ointments: These can help to protect the skin from moisture.
Use incontinence products: These can help to keep the skin dry if the patient is incontinent. Reposition the patient frequently: This helps to reduce pressure and friction on the skin.
Correct Answer is C
Explanation
Choice A rationale:
Side effect: A side effect is an effect of a drug that is secondary to the main intended effect. It is usually predictable and may be either beneficial or harmful. However, constipation is not a common or expected side effect of iron supplements. It is more likely to be an adverse reaction.
Choice B rationale:
Therapeutic effect: The therapeutic effect is the intended effect of a drug, the one that is desired to treat the condition. In this case, the therapeutic effect of the iron supplement would be to increase the patient's iron levels. Constipation is not the desired effect of the iron supplement, so it is not a therapeutic effect.
Choice C rationale:
Adverse reaction: An adverse reaction is an unwanted or harmful reaction to a drug that is not necessarily predictable. It can range from mild to severe. Constipation is a common adverse reaction to iron supplements. It is thought to be caused by the iron binding to undigested food in the intestines, making it harder to pass stool.
Choice D rationale:
Toxicity: Toxicity refers to a poisonous or harmful effect of a drug. It is usually caused by taking too much of a drug or by a drug interacting with another drug or substance. Constipation is not a sign of iron toxicity. Iron toxicity can cause symptoms such as nausea, vomiting, abdominal pain, and diarrhea.
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