A nurse is preparing a patient for discharge after surgery. The patient needs to change a large dressing and manage a drain at home. What instruction by the nurse is most important?

“Call your surgeon if you have any questions at home.”

”Eat a diet high in protein, iron, zinc, and vitamin C.”

“Wash your hands before touching the drain or dressing."

“Be sure you keep all your postoperative appointments.”

Answer and Explanation

The Correct Answer is C

A. “Call your surgeon if you have any questions at home.”

This instruction is important as it encourages the patient to seek help and clarification if they have any concerns or questions about their postoperative care at home. However, while communication with the surgeon is essential, it is not as immediately critical as ensuring proper hand hygiene when dealing with wound care and drain management.

B. ”Eat a diet high in protein, iron, zinc, and vitamin C.”

Nutritional advice is crucial for postoperative recovery, as a balanced diet high in protein, iron, zinc, and vitamin C can promote wound healing and overall recovery. However, while important for long-term recovery and healing, dietary recommendations do not directly address the immediate risk of infection or complications associated with wound care and drain management.

C. “Wash your hands before touching the drain or dressing."

This instruction is the most important in this context because proper hand hygiene is crucial for preventing infections during wound care and drain management. Clean hands significantly reduce the risk of introducing harmful bacteria or contaminants to the surgical site, which can lead to infections and other complications. Ensuring that the patient washes their hands before touching the drain or dressing is a fundamental measure for promoting wound healing and preventing postoperative complications.

D. “Be sure you keep all your postoperative appointments.”

Keeping postoperative appointments is important for ongoing assessment, monitoring, and follow-up care. However, while essential for overall recovery and management of postoperative issues, it is not as immediate or directly related to the patient's ability to manage their dressing and drain at home.

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Correct Answer is A

Explanation

A. The transfusion will begin after the administration of 650 mg of acetaminophen (Tylenol).

This option suggests that the nurse would administer acetaminophen to lower the client's temperature and then proceed with the blood transfusion. While acetaminophen can be used to reduce fever, the decision to administer medication should be made by the healthcare provider after assessing the client's overall condition and determining the cause of the fever. Administering medication without proper evaluation and orders from the healthcare provider is not appropriate.

B. The blood will be held, and the health care provider will be notified.

This option is the correct choice. When a client has an elevated temperature before a blood transfusion, it is standard practice to hold the transfusion and notify the healthcare provider. An elevated temperature could indicate an underlying infection or another condition that needs to be evaluated before proceeding with the transfusion to ensure the client's safety.

C. The transfusion will begin after the administration of an antihistamine.

Administering an antihistamine would not be the appropriate action in response to an elevated temperature before a blood transfusion. Antihistamines are typically used to treat allergic reactions, not fevers. Holding the transfusion and notifying the healthcare provider to assess the situation would be the correct course of action.

D. The transfusion will begin as prescribed.

This option is not appropriate because starting the transfusion without addressing the elevated temperature could pose risks to the client's health. Elevated temperatures may indicate an underlying infection or other conditions that need to be evaluated before proceeding with the transfusion. Holding the transfusion and seeking further guidance from the healthcare provider is the recommended action in this scenario.

A. Morbidly obese patient B. A woman who smokes and takes oral contraceptives or smoke C. Wheelchair-bound patient D. Patient with a humerus fracture E. Patient who underwent a prolonged surgical procedure

Correct Answer is ["A","B","E"]

Explanation

A. Morbidly obese patient: Obesity is a known risk factor for VTE due to several reasons. Morbidly obese individuals often have impaired mobility, which can lead to venous stasis (sluggish blood flow in the veins). Additionally, obesity is associated with inflammation and changes in blood clotting factors, increasing the risk of developing blood clots in the veins.

B. A woman who smokes and takes oral contraceptives or smokes: Both smoking and oral contraceptive use are independent risk factors for VTE. Smoking can cause damage to blood vessels and alter blood clotting mechanisms, while oral contraceptives can increase the risk of blood clots due to hormonal changes.

C. Wheelchair-bound patient: While being wheelchair-bound alone may not always indicate a high risk for VTE, immobility is a significant risk factor for developing blood clots. Prolonged periods of immobility can lead to blood stasis in the veins, making wheelchair-bound patients susceptible to VTE, especially if other risk factors are present.

D. Patient with a humerus fracture: A humerus fracture on its own may not necessarily increase the risk of VTE significantly. However, if the fracture requires immobilization or surgery, especially if it affects the lower extremities or leads to prolonged immobility, the risk of VTE can increase due to decreased blood flow and stasis.

E. Patient who underwent a prolonged surgical procedure: Prolonged surgical procedures often involve anesthesia, immobility during surgery, and postoperative immobilization, all of which can contribute to venous stasis and increase the risk of developing VTE. Additionally, the surgical trauma itself can trigger inflammatory responses and alterations in blood clotting factors, further elevating the risk of blood clots.

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A nurse is preparing a patient for discharge after surgery. The patient needs to change a large dressing and manage a drain at home. What instruction by the nurse is most important?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse takes a client's temperature before giving a blood transfusion. The temperature is 100 F orally. The nurse reports the finding to the registered nurse (RN) and anticipates that which action will take place?

Correct Answer is A

Explanation

A nurse recently hired to the preoperative area learns that certain patients are at higher risk for venous thromboembolism (VTE). Which patients are considered to be at high risk? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

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