A nurse is reviewing the client's medical record in the presurgical holding area. Which of the following places the client at risk for a surgical site infection?
Body mass index (BMI) of 19
History of deep vein thrombosis
Aged 55 years old
Type 2 diabetes mellitus
The Correct Answer is D
A. Body mass index (BMI) of 19:
A BMI of 19 falls within the normal weight range. While obesity (high BMI) is a known risk factor for surgical complications, including SSIs, having a lower BMI (underweight) like 19 may not directly increase the risk of SSIs. However, extreme malnutrition or low BMI due to underlying health conditions could potentially impact wound healing and immune function, indirectly contributing to infection risk.
B. History of deep vein thrombosis (DVT):
A history of deep vein thrombosis is a risk factor for surgical complications, including SSIs. Patients with a history of DVT may have impaired circulation or underlying vascular issues, which can affect tissue perfusion, wound healing, and increase the risk of infections.
C. Aged 55 years old:
Age is a risk factor for surgical complications, including SSIs. Older adults, typically defined as those aged 65 and above, may have reduced immune function, slower wound healing, and underlying health conditions that contribute to infection risk. While 55 years old is not considered advanced age in terms of surgical risk, older age in general is associated with a higher risk of complications.
D. Type 2 diabetes mellitus:
Type 2 diabetes mellitus is a significant risk factor for SSIs. Diabetes can impair immune function, delay wound healing, and increase susceptibility to infections. Poorly controlled blood sugar levels in diabetic patients can further exacerbate the risk of SSIs post-surgery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
A. "Bake or grill the meat rather than frying it."
This statement is more related to reducing fat intake rather than managing sodium levels. While reducing fried foods can be beneficial for overall health, it doesn't directly address the issue of sodium intake, which is crucial in managing hypernatremia.
B. “Check your radial pulse twice a day.”
Checking the radial pulse is a method used to monitor heart rate and rhythm. It is not directly related to managing sodium levels or hypernatremia. Although monitoring vital signs is important in general health care, it is not specific to addressing mild hypernatremia.
C. "Read food labels to determine sodium content."
This statement is the correct choice. Managing sodium intake is a key component in managing hypernatremia. Reading food labels helps patients identify high-sodium foods and make choices that are lower in sodium content, which can be crucial in preventing or managing mild hypernatremia.
D. “Weigh yourself every morning and every night."
While regular weight monitoring can be important for certain health conditions, it is not directly related to managing mild hypernatremia. Weight changes may occur with fluid retention or loss, but monitoring sodium intake and hydration status is more directly relevant to managing hypernatremia.
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