A patient is scheduled for an elective hernia repair. The patient has been taking antibiotics for an infection and has experienced episodes of diarrhea while on the antibiotic regimen.
What surgical and post-surgical risk should the registered nurse monitor based on this antibiotic use?
Hemorrhage
Cardiovascular Collapse
Electrolyte Imbalances
Respiratory Paralysis .
The Correct Answer is C
Choice A Rationale:
Hemorrhage is not a direct risk associated with antibiotic use and diarrhea. While severe diarrhea can lead to fluid loss and potentially hypovolemia, it's not the most significant risk in this context.
Antibiotics themselves don't typically cause bleeding issues unless they specifically interfere with clotting factors, which isn't common.
The nurse should monitor for signs of bleeding, but it's not the primary concern based on the patient's history of antibiotic use and diarrhea.
Choice B Rationale:
Cardiovascular collapse is a serious complication, but it's not directly linked to antibiotic use and diarrhea. It can occur due to various factors like severe dehydration, electrolyte imbalances, or underlying heart conditions. The nurse should be vigilant for signs of cardiovascular instability, but it's not the most likely risk in this scenario.
Choice C Rationale:
Electrolyte imbalances are a significant concern for patients with diarrhea, especially those on antibiotics. Antibiotics can disrupt the balance of gut bacteria, which play a crucial role in electrolyte absorption. Diarrhea further exacerbates electrolyte loss through fluid loss.
Key electrolytes to monitor include:
Potassium: Essential for nerve and muscle function, including the heart. Low potassium (hypokalemia) can lead to muscle weakness, fatigue, cramps, and potentially heart arrhythmias.
Sodium: Vital for fluid balance and nerve signaling. Low sodium (hyponatremia) can cause confusion, seizures, and coma.
Chloride: Also important for fluid balance and acid-base balance.
Magnesium: Crucial for muscle function, nerve transmission, and energy production. Low magnesium (hypomagnesemia) can cause muscle cramps, tremors, and heart arrhythmias.
The nurse should closely monitor the patient's electrolyte levels and watch for signs of imbalance, such as muscle weakness, fatigue, cramps, confusion, or heart rhythm abnormalities.
Choice D Rationale:
Respiratory paralysis is not a typical risk associated with antibiotic use or diarrhea.
It's more commonly linked to neuromuscular disorders, certain medications, or severe electrolyte imbalances (especially low potassium or calcium).
While the nurse should be aware of potential respiratory complications, it's not the most likely concern in this case.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Anatomy: The bladder is a hollow, muscular organ located in the lower abdomen, just behind the pubic bone. It stores urine until it is emptied through urination. The area between the symphysis pubis (the joint where the two pubic bones meet) and the umbilicus (belly button) is directly over the bladder, making it the most appropriate place to palpate for bladder distention.
Signs of bladder distention: When the bladder is distended, it can be felt as a firm, round mass in the lower abdomen. The patient may also experience discomfort, pressure, or an urge to urinate.
Nursing assessment: Palpation is a key nursing assessment skill used to evaluate the size, shape, and position of organs within the abdomen. In this case, palpation helps the nurse to determine if the bladder is distended and to assess the severity of the distention.
Clinical significance: Bladder distention can occur for a variety of reasons, including:
Postoperative urinary retention due to anesthesia or pain medications
Urinary tract obstruction (e.g., from a kidney stone or enlarged prostate)
Neurological conditions that affect bladder function (e.g., spinal cord injury, multiple sclerosis)
Dehydration
Certain medications (e.g., diuretics, anticholinergics)
Prompt intervention: Bladder distention can lead to complications such as urinary tract infections, kidney damage, and discomfort. It's important for the nurse to identify and address bladder distention promptly to prevent these complications.
Correct Answer is A
Explanation
Skin breakdown:
Prolonged exposure to urine, especially in the presence of incontinence briefs, can irritate and macerate the skin, leading to breakdown.
Factors contributing to skin breakdown:
Moisture from urine:
Creates a warm, moist environment ideal for bacterial growth.
Disrupts the skin's natural barrier function, making it more susceptible to damage.
Friction from incontinence briefs:
Can rub against the skin, causing irritation and further damage.
Chemical irritants in urine:
Ammonia and other substances in urine can further irritate and damage the skin.
Signs of skin breakdown:
Redness, warmth, tenderness, or swelling of the skin.
Blisters, erosions, or ulcers.
Pain or discomfort.
Prevention of skin breakdown:
Frequent changing of incontinence briefs (as soon as they become wet or soiled).
Thorough cleansing of the skin with mild soap and water after each change.
Application of a skin barrier cream or ointment to protect the skin.
Use of breathable incontinence briefs that allow air to circulate.
Monitoring of the skin for signs of breakdown and seeking prompt medical attention if any occur. Urinary tract infections (UTIs):
Bacteria from the skin can enter the urinary tract through the urethra, leading to infection.
Factors increasing UTI risk in those with incontinence:
Incomplete bladder emptying:
Residual urine in the bladder provides a breeding ground for bacteria.
Use of incontinence briefs:
Can trap moisture and bacteria near the urethra.
Difficulty with personal hygiene:
May lead to the spread of bacteria from the skin to the urinary tract.
Signs of a UTI:
Frequent urination.
Pain or burning during urination.
Urgency to urinate.
Blood in the urine.
Cloudy or foul-smelling urine.
Prevention of UTIs:
Maintaining good personal hygiene.
Drinking plenty of fluids to help flush bacteria from the urinary tract.
Promptly emptying the bladder when the urge to urinate is felt.
Seeking medical attention if any signs of a UTI occur.
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