In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?

Palpate all peripheral pulse points for volume and strength.

Monitor the amount of drainage from the client's incision.

Observe both lower extremities for redness and swelling.

Evaluate the client's ability to use an incentive spirometer.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. Observe both lower extremities for redness and swelling.

Choice A rationale:

Palpating all peripheral pulse points for volume and strength is important for assessing circulation, but it does not directly evaluate the effectiveness of intermittent pneumatic compression (IPC) devices. IPC devices are primarily used to prevent deep vein thrombosis (DVT) and improve venous return, so monitoring for signs of DVT is more relevant.

Choice B rationale:

Monitoring the amount of drainage from the client’s incision is crucial for assessing wound healing and detecting potential infections, but it is not related to the effectiveness of IPC devices.

Choice C rationale:

Observing both lower extremities for redness and swelling is the most important assessment for evaluating the effectiveness of IPC devices. Redness and swelling can be signs of DVT, which IPC devices are designed to prevent. Therefore, this assessment directly measures whether the devices are functioning as intended.

Choice D rationale:

Evaluating the client’s ability to use an incentive spirometer is important for preventing postoperative pulmonary complications, but it does not assess the effectiveness of IPC devices.

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Correct Answer is C

Explanation

The clinical scenario involves postoperative management of a surgical site in a patient colonized with methicillin-resistant Staphylococcus aureus. Successful intervention requires applying principles of wound hygiene, bacterial proliferation kinetics, and aseptic technique to mitigate localized moisture which fosters rapid staphylococcal replication and subsequent infection.

Choice A rationale: Elevated white blood cell counts, typically exceeding 11,000 mm3, indicate a systemic inflammatory response or active infection. While monitoring hematologic data is essential for detection, it is a reactive measure rather than a proactive intervention to prevent localized MRSA recurrence.

Choice B rationale: Contact precautions prevent the horizontal transmission of resistant pathogens between the patient and others. While vital for institutional infection control and public health safety, these measures do not directly address the localized physiological environment of the patient's own surgical incision.

Choice C rationale: Saturated dressings create a warm, moist environment that facilitates capillary action, pulling contaminants into the wound. Maintaining a dry, sterile environment inhibits the colonization of methicillin-resistant Staphylococcus aureus, as moisture promotes the rapid exponential growth of these resistant gram-positive cocci.

Choice D rationale: Face masks primarily provide protection against respiratory droplet transmission. While beneficial for preventing the introduction of oropharyngeal flora into a sterile field, they are less critical than moisture control for preventing MRSA recurrence, which is primarily spread through direct or indirect contact.

A. Remove electrodes and observe for skin redness. B. Decrease the strength of the electrical signals. C. Check the amount of gel coating on the electrodes. D. Determine if the sensation feels uncomfortable.

Correct Answer is D

Explanation

A) Incorrect - Skin redness might indicate irritation, but the initial focus should be on the client's sensation.
B) Incorrect - Decreasing the strength of the electrical signals might be premature if the sensation is normal.
C) Incorrect - The amount of gel coating on the electrodes might not be the primary issue if the client is feeling a tingling sensation.
D) Correct- A tingling sensation is normal and expected when using a TENS unit, and it does not indicate any harm or damage to the skin or nerves. However, the sensation should not be painful or unpleasant for the client, and the nurse should adjust the intensity of the electrical signals accordingly.

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In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client with persistent low back pain has received a prescription for an electronic stimulator (TENS) unit. After the nurse applies the electrodes and turns on the power, the client reports feeling a tingling sensation. How should the nurse respond?

Correct Answer is D

Explanation

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