A nurse is preparing the skin of a client scheduled for cardiac surgery. What is the purpose of surgical skin cleaning preparation?

Assessing the surgical site before surgery

Providing comfort for the client

Reducing the risk of post-operative wound infection

Sterilizing the skin for easier scalpel cutting

Answer and Explanation

The Correct Answer is C

A. Assessing the surgical site before surgery: While assessing the surgical site is important, it is not the primary purpose of skin cleaning preparation. The focus is on reducing infection risk.
B. Providing comfort for the client: Comfort may be a secondary benefit, but it is not the main goal of surgical skin cleaning. The primary purpose is to reduce infection risk.
C. Reducing the risk of post-operative wound infection: Surgical skin cleaning preparation is aimed at minimizing the number of microorganisms on the skin to reduce the risk of postoperative wound infections. This is the key reason for preoperative skin preparation.
D. Sterilizing the skin for easier scalpel cutting: Skin cannot be completely sterilized, and the ease of scalpel cutting is not related to the cleanliness of the skin. The goal is infection control, not making the skin easier to cut.

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Correct Answer is D

Explanation

A. Level of consciousness: While important, it follows the assessment of vital signs to ensure the client's overall stability.
B. Condition of drains: This is relevant but not as immediate as assessing the stability of vital signs.
C. Appearance of the surgical dressing: This is important but secondary to ensuring the client’s vital signs are stable.
D. Stability of vital signs: This is the most critical next assessment after ensuring a patent airway, as vital signs reflect the client's immediate physiological status and stability.

A. Poorly controlled pain, moves all extremities, reports continued nausea B. 2-hour total urinary output of 30 mL, pulse oximetry 94% on 3L oxygen, turning from side to side C. Afebrile, adventitious breath sounds, responds to painful stimuli D. SaO2 of 95%, vital signs stable for last 30 minutes, active gag reflex

Correct Answer is D

Explanation

A. Poorly controlled pain, moves all extremities, reports continued nausea: Poorly controlled pain and nausea are not ideal for discharge, as they indicate the patient might need further monitoring and management.
B. 2-hour total urinary output of 30 mL, pulse oximetry 94% on 3L oxygen, turning from side to side: Low urinary output and low oxygen saturation indicate potential complications that require further assessment and treatment.
C. Afebrile, adventitious breath sounds, responds to painful stimuli: Responding to painful stimuli and adventitious breath sounds suggest the patient may still be experiencing complications and is not ready for discharge.
D. SaO2 of 95%, vital signs stable for last 30 minutes, active gag reflex: This response indicates stable oxygen saturation, stable vital signs, and an active gag reflex, suggesting the patient is ready for discharge from the PACU.

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A nurse is preparing the skin of a client scheduled for cardiac surgery. What is the purpose of surgical skin cleaning preparation?

Nursing Test Bank

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