A nurse is teaching a patient about wound care after a minor surgical procedure. Which of the following instructions should the nurse include? (Select all that apply.)
Keep the dressing clean and dry.
Change the dressing every day or as needed.
Wash the wound with soap and water.
Apply antibiotic ointment to the wound.
Report any signs of infection to the physician or surgeon.
Correct Answer : A,B,E
Choice A reason:
Keeping the dressing clean and dry prevents contamination and infection of the wound. It also helps the wound heal faster by protecting it from further injury. This is a standard instruction for wound care after a minor surgical procedure.
Choice B reason:
Changing the dressing every day or as needed helps keep the wound clean and allows the doctor or nurse to monitor the healing process. It also prevents the dressing from sticking to the wound or becoming too wet or soiled. This is another common instruction for wound care after a minor surgical procedure.
Choice C reason:
Washing the wound with soap and water is not recommended for wound care after a minor surgical procedure. Soap can irritate the wound and delay healing. Water can wash away the protective scab and cause bleeding. The wound should be rinsed with sterile water or saline solution instead.
Choice D reason:
Applying antibiotic ointment to the wound is not advised for wound care after a minor surgical procedure unless prescribed by the doctor or surgeon. Antibiotic ointment can cause allergic reactions, increase resistance to bacteria, or interfere with the healing process. The wound should be covered with a sterile dressing and left alone.
Choice E reason:
Reporting any signs of infection to the physician or surgeon is an important instruction for wound care after a minor surgical procedure. Signs of infection include redness, swelling, warmth, pain, pus, fever, or foul odor. Infection can delay healing, cause complications, or spread to other parts of the body.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
The client has signs of a possible infection, such as low-grade fever, foul-smelling vaginal discharge and lower abdominal tenderness. These are complications of hysterectomy that require immediate attention from the provider. The provider may order further tests, such as a wound culture or blood tests, and prescribe antibiotics or other treatments. Therefore, notifying the provider is the first action the nurse should take.
Choice B reason:
Obtaining a wound culture from the surgical site may be necessary to identify the type of infection and the appropriate antibiotic therapy. However, this is not the first action the nurse should take. The nurse should first notify the provider of the findings and follow their orders.
Choice C reason:
Administering an antibiotic as ordered may help treat the infection and reduce the risk of further complications. However, this is not the first action the nurse should take. The nurse should first notify the provider of the findings and obtain a wound culture if ordered to determine the best antibiotic for the client.
Choice D reason:
Increasing the frequency of perineal care may help prevent or reduce infection by keeping the area clean and dry. However, this is not the first action the nurse should take. The nurse should first notify the provider of the findings and administer an antibiotic as ordered to treat the infection.
Correct Answer is A
Explanation
Choice A reason:
Tingling in the fingers and toes is a sign of paresthesia, which is a common symptom of hypocalcemia. Hypocalcemia occurs when the blood calcium level is too low, which can happen after a thyroidectomy if the parathyroid glands are damaged or removed. The parathyroid glands produce parathyroid hormone, which regulates calcium balance in the body. Without enough parathyroid hormone, calcium levels drop and cause neuromuscular irritability and numbness or tingling sensations.
Choice B reason:
Difficulty swallowing and speaking is not a specific sign of hypocalcemia, but rather a possible complication of a thyroidectomy due to injury to the recurrent laryngeal nerve. This nerve innervates the muscles of the larynx, which control voice production and swallowing. Damage to this nerve can cause hoarseness, weak voice, or vocal cord paralysis.
Choice C reason:
Dry mouth and increased thirst are not signs of hypocalcemia, but rather signs of dehydration. Dehydration can occur for various reasons, such as fluid loss, inadequate fluid intake, or increased fluid needs. Dehydration can affect the electrolyte balance in the body, but it does not directly cause hypocalcemia.
Choice D reason:
Muscle weakness and fatigue are not specific signs of hypocalcemia, but rather general signs of malaise. Malaise can occur for various reasons, such as infection, inflammation, stress, or chronic illness. Malaise can affect the physical and mental well-being of a person, but it does not directly cause hypocalcemia.
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