A post-operative patient is at risk for developing a wound infection. Which of the following nursing assessments is the highest priority to prevent this complication?

Monitoring the patient's vital signs

Assessing the patient's pain level

Inspecting the surgical incision site for redness, swelling

Assessing the patient's fluid intake and output

Answer and Explanation

The Correct Answer is C

A.   While important for overall patient assessment, it's not the most direct way to monitor for a wound infection.
B.   Pain can indicate a wound infection, but it's not as specific as directly inspecting the wound.
C.   This is the most direct way to assess for early signs of a wound infection. Redness, swelling, warmth, and drainage are classic signs of infection.
D.   Important for overall patient care, but not specifically related to wound infection prevention.

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Correct Answer is D

Explanation

A. While asking appropriate questions demonstrates that the partner is engaged and seeking understanding, it alone does not indicate that they are ready to perform the procedure independently.

B. Being able to verbalize all steps in the procedure shows that the partner has knowledge and understanding of the process. However, verbalizing alone does not confirm that they can perform the procedure accurately and safely. Practical skills and hands-on competence are crucial for readiness.
C. Attending a class provides important theoretical knowledge and information about tracheostomy care. However, attending a class by itself does not guarantee that the partner has developed the necessary skills to perform suctioning independently.
D. The ability to perform the procedure independently indicates that the partner has acquired the necessary skills and confidence to carry out suctioning safely and effectively. It shows practical proficiency, which is essential for readiness for discharge. The partner’s ability to perform suctioning without assistance demonstrates that they can handle the procedure in real-life situations.

A. Abdominal pain B. Lethargy C. Numbness of fingers D. Dry skin

Correct Answer is B

Explanation

A. Abdominal pain is not a direct manifestation of respiratory acidosis. However, it may be associated with other conditions or complications but is not a primary indicator of respiratory acidosis.
B. Lethargy or drowsiness is a common symptom of respiratory acidosis. The increased CO₂ levels lead to an acidic environment that can affect brain function, resulting in decreased alertness, confusion, or drowsiness.
C. Numbness or tingling of the fingers is more commonly associated with respiratory alkalosis, which is characterized by a decreased level of CO₂ and increased blood pH. This condition can cause peripheral numbness and tingling due to altered blood pH affecting nerve function.
D. Dry skin is not a direct manifestation of respiratory acidosis. While it might be a sign of dehydration or other systemic issues, it is not specifically linked to respiratory acidosis.

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A post-operative patient is at risk for developing a wound infection. Which of the following nursing assessments is the highest priority to prevent this complication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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