The nurse assesses the following data from a patient with diabetes mellitus who is 4 days postoperative for repair of an abdominal aortic aneurysm. Which assessment finding is of greatest concern for the nurse?
Vesicular breath sounds in the lung bases
Temperature 38.5° C (101.4° F)
Incision pain rating of 6 out of 10
Blood glucose of 164 mg/dL
The Correct Answer is B
Postoperative clients with diabetes mellitus are at increased risk for infection, poor wound healing, and complications such as pneumonia or sepsis.
Rationale for correct answer:
B. Temperature 38.5°C (101.4°F): A postoperative fever (≥38.5°C) in a client with diabetes mellitus is a significant red flag for infection. Due to impaired immune response and delayed wound healing in diabetics, a fever can indicate a developing or ongoing infection.
Rationale for incorrect answers:
A. Vesicular breath sounds in the lung bases are normal findings in the peripheral lung fields. This is not concerning and indicates that the lung bases are clear and the client does not have adventitious sounds which could indicate fluid overload or pneumonia.
C. Incision pain rating of 6 out of 10: While a pain rating of 6/10 suggests moderate pain and should be managed appropriately, pain is expected after major abdominal surgery. Unless the pain is associated with signs of infection or dehiscence it is not the most concerning finding.
D. Blood glucose of 164 mg/dL is slightly elevated for a postoperative diabetic patient but is not critically high. Mild hyperglycemia can occur postoperatively due to stress and corticosteroid use.
Take home points:
- Postoperative fever in a diabetic patient is a potential sign of infection.
- Routine postoperative pain and slightly elevated glucose levels are expected findings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Patients placed under isolation precautions, such as for pulmonary tuberculosis (TB), may experience emotional distress, including anger, anxiety, loneliness, or depression. These feelings are often due to sensory deprivation, social isolation, and limited interaction with others.
Rationale for correct answer:
C. Explain the reasons for isolation procedures and provide meaningful stimulation: Helping the patient understand why isolation is necessary, reducing feelings of confusion and anger. Providing meaningful stimulation combats boredom and emotional distress while maintaining safety.
Rationale for incorrect answers:
A. Provide a dark, quiet room to calm the patient: While reducing environmental stimuli may help anxious patients, providing a dark, quiet room may actually worsen feelings of isolation, boredom, and depression.
B. Reduce the level of precautions to keep the patient from becoming angry: Reducing precautions due to the patient's emotional response puts others at risk of infection and is never an acceptable solution.
D. Limit family and other caregiver visits to reduce the risk of spreading the infection: While visitor precautions are important, completely limiting family and caregiver interactions can worsen the patient’s isolation.
Take home points:
- Maintaining engagement through meaningful activities can greatly improve cooperation and emotional well-being without compromising safety.
- These include: books, TV, music, virtual family contact.
Correct Answer is A
Explanation
Infection prevention and control are essential components of nursing practice that safeguard both clients and healthcare providers. In healthcare settings, infections can be transmitted through direct contact, droplets, airborne particles, or contaminated surfaces.
Rationale for correct answer:
A. Thorough hand hygiene: Hand hygiene removes or destroys transient microorganisms. It interrupts the chain of infection by removing transient microorganisms from the hands before they can be spread to others or enter the body through mucous membranes or broken skin.
Rationale for incorrect answers:
B. Wearing gloves and masks when providing direct client care: Gloves and masks provide a barrier to infectious agents. However, they are not substitutes for hand hygiene and may be misused or improperly removed, potentially increasing the risk of contamination.
C. Implementing appropriate isolation precautions: Isolation precautions (e.g., contact, droplet, airborne) help limit the transmission of specific pathogens. They are essential for infection control when a known pathogen exists.
D. Administering broad-spectrum prophylactic antibiotics: Antibiotics may be used in select cases (e.g., pre-op or immunocompromised clients), but overuse contributes to antimicrobial resistance and disrupts normal flora.
Take home points:
- Hand hygiene is the most effective and universally applicable infection control measure in nursing practice.
- It should be performed before and after client contact, after removing gloves, and after contact with bodily fluids or contaminated surfaces.
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