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 D
Explanation
Choice A rationale:
Planning is conducted during the initial stage of Lewin's change model, known as the unfreezing phase. This phase involves creating awareness of the need for change, building support, and developing a plan for implementation. It's not part of the refreezing phase.
Choice B rationale:
Change is initiated during the second stage of Lewin's change model, known as the change or transition phase. This phase involves implementing the planned changes, providing training and support, and addressing resistance. It's not part of the refreezing phase.
Choice C rationale:
The need for change is recognized during the unfreezing phase, not the refreezing phase. Recognizing the need for change is a crucial step in initiating the change process, but it's not the focus of the refreezing phase.
Choice D rationale:
Change becomes permanent during the refreezing phase. It involves solidifying the new behaviors and practices that have been implemented during the change phase. This is achieved through various strategies, such as:
Reinforcement of the new behaviors through rewards, recognition, and positive feedback
Integration of the new behaviors into organizational policies, procedures, and structures
Creation of a supportive culture that encourages and sustains the change
Ongoing monitoring and evaluation to ensure that the change is sustained over time
Correct Answer is D
Explanation
Choice A rationale:
Sterile dressing changes each morning are not directly related to the finding in question. While maintaining sterile dressings is important for postoperative wound care, it's not the primary intervention based on the specific finding you've presented. I'll need more information about the finding to determine the most appropriate rationale for this choice.
Choice B rationale:
Administering pain medications as needed is a common postoperative intervention, but it's not always the most crucial one depending on the patient's condition and the specific finding. It's important to assess the patient's pain level and administer medications accordingly, but pain management shouldn't overshadow other essential interventions.
Choice C rationale:
Conducting a head-to-toe assessment each shift is a comprehensive assessment, but it may not be necessary for every postoperative patient in every situation. The frequency and extent of assessments should be tailored to the patient's individual needs and the specific findings.
Choice D rationale:
Monitoring respirations and breath sounds is often the most critical postoperative intervention, as it allows for early detection of respiratory complications such as pneumonia, atelectasis, or pulmonary embolism. These complications can be life threatening, so prompt identification and intervention are essential.
Specific reasons why monitoring respirations and breath sounds is essential based on the finding (which you haven't provided) could include:
Evidence of respiratory distress or compromise
Changes in breathing patterns or sounds
Decreased oxygen saturation levels
Increased work of breathing
Risk factors for respiratory complications (e.g., type of surgery, underlying lung disease)
I'm ready to provide a more comprehensive rationale for each choice once you share the specific finding that prompted this question.
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