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Exhibits

Data is evaluated to determine possible condition and appropriate interventions. Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

Answer and Explanation

The Correct Answer is []

Condition:

Postoperative infection

2 Actions:

Administer prescribed antibiotics.
Culture wound drainage.

2 Parameters:

Temperature.
White blood cell count.

Rationale for correct condition:

A postoperative infection is the most likely condition because the patient has elevated white blood cell count (11,000/mm³) and a slightly elevated temperature (99.8°F). These findings suggest a systemic inflammatory response, potentially from infection. The presence of a recent surgical wound increases the risk of bacterial contamination. The absence of redness or drainage does not rule out deeper tissue infection. The patient’s symptoms align with early signs of an infectious process.

Rationale for the two correct actions:

Administer prescribed antibiotics: Antibiotics target potential bacterial infection, which is critical to prevent further complications such as systemic infection or sepsis.
Culture wound drainage: This identifies the causative organism and guides appropriate antibiotic therapy. Even if the wound appears clean externally, culturing can confirm or rule out deeper infection.

Rationale for parameters to monitor:

Temperature: Monitoring temperature helps identify trends in fever, a common sign of infection progression or resolution.
White blood cell count: Elevated levels are a marker of infection or inflammation. Monitoring changes in WBC count can indicate if treatment is effective.

Rationale for incorrect conditions:

Surgical rash: A rash is not indicated in the notes, and the elevated WBC count and temperature do not suggest a dermatologic issue.
Contractures: No evidence suggests reduced mobility or positioning problems causing contractures.
Deep vein thrombosis (DVT): The client’s normal vital signs and lack of redness or swelling in the residual limb make DVT less likely.

Rationale for incorrect actions to take:

Request NPO prescription: There is no evidence of gastrointestinal issues or surgery requiring this intervention.
Elevate residual limb to reduce swelling: While useful in managing swelling, there is no current sign of significant limb edema requiring elevation.
Educate on incentive spirometer use: This is preventive for respiratory complications but unrelated to infection management.

Rationale for incorrect parameters to monitor:

Adherence to activity prescription: While important for recovery, it does not directly address infection.
Residual limb redness or swelling: Although relevant to infection, there is no current evidence of redness or swelling in the notes.
Pain intensity and characteristics: Pain is already being managed with morphine, and its current level (5/10) does not directly indicate infection.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: Continuous cardiac monitoring is crucial for a client who has suffered an electrical injury. Electrical injuries can cause arrhythmias and other cardiac complications, which may not be immediately apparent. Continuous monitoring allows for the early detection and treatment of any cardiac abnormalities, which is vital for the patient's safety and recovery.

Choice B reason: Evaluating the level of consciousness is important for any patient, especially those with significant injuries, but it is not the most critical intervention in this scenario. While neurological assessments are part of comprehensive care, the immediate risk posed by cardiac complications from the electrical injury takes precedence.

Choice C reason: Performing passive range of motion exercises is beneficial for preventing contractures and maintaining joint mobility in immobile patients. However, it is not the most urgent intervention in the context of an electrical injury, where cardiac monitoring is paramount.

Choice D reason: Assessing lung sounds every 4 hours is a valuable part of monitoring for respiratory complications, particularly in burn patients. However, the immediate cardiac risks associated with electrical injuries necessitate continuous cardiac monitoring as the priority intervention.

A. Review written and verbal instructions for a reduced sodium diet. B. Teach strategies for aseptic administration of the eye drops. C. Describe how the use of the eye drops will help improve peripheral vision. D. Teach to apply pressure over the inner eye corner after eye drops. E. Explain the need to continue eye drops for the rest of their life.

Correct Answer is ["B","D","E"]

Explanation

Choice A reason: Reviewing written and verbal instructions for a reduced sodium diet is not directly related to the management of primary open-angle glaucoma (POAG). While a healthy diet can contribute to overall well-being, dietary sodium does not have a significant impact on intraocular pressure or glaucoma management. Therefore, this intervention does not directly address the client's primary condition of POAG.

Choice B reason: Teaching strategies for aseptic administration of the eye drops is a critical intervention for clients with POAG. Proper administration of ophthalmic drops is essential to avoid contamination and infection. Aseptic techniques include washing hands before administering the drops, avoiding touching the dropper tip to any surface (including the eye), and ensuring that the dropper cap is replaced tightly after use. These measures help maintain the sterility of the medication and prevent complications such as eye infections, which can exacerbate the client's condition.

Choice C reason: Describing how the use of the eye drops will help improve peripheral vision is not entirely accurate in the context of POAG. The primary goal of ophthalmic drops for POAG is to lower intraocular pressure and prevent further damage to the optic nerve, thereby preserving the remaining vision. These drops do not typically improve peripheral vision that has already been lost. Educating the client with accurate information about the purpose and benefits of the drops helps set realistic expectations and encourages adherence to the treatment regimen.

Choice D reason: Teaching the client to apply pressure over the inner eye corner (punctal occlusion) after administering eye drops is an important intervention. Punctal occlusion helps prevent the medication from draining into the tear duct and being absorbed systemically. This technique increases the contact time of the medication with the eye, enhancing its effectiveness and reducing potential systemic side effects. Clients should be instructed to gently press the inner corner of the eye for a few minutes after instilling the drops to ensure maximum benefit.

Choice E reason: Explaining the need to continue eye drops for the rest of their life is essential for clients with POAG. Glaucoma is a chronic condition that requires lifelong management to control intraocular pressure and prevent progression of the disease. Discontinuing the medication can lead to elevated intraocular pressures and irreversible vision loss. Clients should understand the importance of adherence to their prescribed treatment regimen and the lifelong commitment to managing their condition to preserve their vision and quality of life.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client’s plan of care?

Correct Answer is A

Explanation

Correct Answer is ["B","D","E"]

Explanation

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