A nurse is caring for a patient with a postsurgical wound. When planning care, which goal will be the priority?

Promote positive nitrogen balance.

Facilitate neutral nitrogen balance.

Reduce dependent nitrogen balance.

Maintain negative nitrogen balance.

Answer and Explanation

The Correct Answer is A

Choice A reason: Promoting positive nitrogen balance is critical for postsurgical wound healing, as it indicates adequate protein intake for tissue repair. Surgery increases metabolic demand, depleting amino acids needed for collagen synthesis and immune function. Positive balance supports fibroblast activity and wound tensile strength, reducing infection risk and promoting recovery in the healing process.

Choice B reason: Neutral nitrogen balance maintains protein homeostasis but is insufficient for postsurgical patients, who require excess protein for tissue repair. Surgery induces catabolism, increasing nitrogen loss via urine. Neutral balance does not provide the surplus amino acids needed for collagen formation and immune response, slowing wound healing and increasing complication risks.

Choice C reason: Reducing dependent nitrogen balance is not a recognized medical goal. Nitrogen balance reflects protein metabolism, critical for wound healing. Postsurgical patients need positive balance to supply amino acids for tissue regeneration. This option is vague and irrelevant, as it does not address the physiological need for increased protein synthesis post-surgery.

Choice D reason: Maintaining negative nitrogen balance indicates protein catabolism exceeding synthesis, detrimental to wound healing. Postsurgical stress increases cortisol, promoting protein breakdown. Negative balance impairs collagen production and immune function, delaying wound closure and increasing infection risk. Positive nitrogen balance is essential to support tissue repair and recovery in surgical patients.

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Correct Answer is D

Explanation

Choice A reason: Urinary status, such as output, monitors hydration and kidney function post-surgery but is unrelated to safe oral intake. Abdominal surgery risks paralytic ileus, where intestinal motility ceases, increasing aspiration risk if food is consumed. Bowel sounds indicate gastrointestinal function recovery, making urinary status a secondary consideration for dietary decisions.

Choice B reason: Skin turgor assesses hydration but does not determine readiness for oral intake post-surgery. Abdominal surgery can impair peristalsis, causing ileus, which risks vomiting or obstruction if food is introduced prematurely. Assessing bowel sounds confirms intestinal motility, critical for safe eating, while skin turgor is irrelevant to gastrointestinal recovery.

Choice C reason: Pain level is important for patient comfort but not the primary consideration for eating post-surgery. Pain may indicate complications, but absent bowel sounds suggest ileus, a condition where the gut lacks motility, risking aspiration. Bowel sounds confirm peristalsis, ensuring safe digestion, making pain a secondary factor in this context.

Choice D reason: Bowel sounds indicate gastrointestinal motility, critical after abdominal surgery to prevent complications like ileus. Absent sounds suggest impaired peristalsis, increasing risks of vomiting or obstruction if food is consumed. Auscultating active bowel sounds confirms the gut’s readiness to process food, making this the primary consideration before allowing eating to ensure safety.

A. Having chest pain B. Pulse rate of 108 C. History of angina D. Oxygen is needed.

Correct Answer is C

Explanation

Choice A reason: In SBAR (Situation, Background, Assessment, Recommendation), chest pain is part of the Situation (S), describing the current issue. Background (B) includes relevant medical history, like angina, which causes chest pain due to myocardial ischemia from reduced coronary blood flow. Chest pain is the presenting symptom, not historical context, making it incorrect for B.

Choice B reason: Pulse rate of 108 is part of the Assessment (A) in SBAR, reflecting current vital signs. Background (B) provides historical context, such as the patient’s angina diagnosis, which predisposes to myocardial ischemia. Tachycardia may result from pain or hypoxia but is a current finding, not historical data, making it incorrect for B.

Choice C reason: History of angina is the Background (B) in SBAR, providing relevant medical history. Angina, caused by coronary artery narrowing, reduces myocardial oxygen supply, leading to chest pain. This context informs the current episode of pain and tachycardia, guiding assessment and treatment, making it the correct data for the Background component.

Choice D reason: Oxygen is needed is part of the Recommendation (R) in SBAR, suggesting an intervention. Background (B) includes past medical history, like angina, which explains the patient’s predisposition to chest pain. Recommending oxygen addresses current hypoxia but is not historical data, making it inappropriate for the Background section of SBAR.

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A nurse is caring for a patient with a postsurgical wound. When planning care, which goal will be the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient had abdominal surgery 2 hours ago. She is stating that she is hungry and would like something to eat. What is the first consideration that the nurse must make before allowing the patient to eat?

Correct Answer is D

Explanation

A patient was admitted 2 days ago with pneumonia and a history of angina. The patient is now having chest pain with a pulse rate of 108. Using the SBAR, which piece of data will the nurse use for B?

Correct Answer is C

Explanation

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