The nurse determines that an adult client who is admitted to the postanesthesia care unit (PACU) following abdominal surgery has a tympanic temperature of 94.6°F (34.8°C), a heart rate of 88 beats per minute, a respiratory rate of 14 breaths per minute, and a blood pressure of 94/68 mm Hg. Which intervention should the nurse implement first?

Condition:

Postoperative infection

2 Actions:

1. Administer prescribed antibiotics.
2. Culture wound drainage.

2 Parameters:

1. Temperature.
2. 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:

1. Administer prescribed antibiotics: Antibiotics target potential bacterial infection, which is critical to prevent further complications such as systemic infection or sepsis.
2. 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:

1. Temperature: Monitoring temperature helps identify trends in fever, a common sign of infection progression or resolution.
2. 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:

1. Surgical rash: A rash is not indicated in the notes, and the elevated WBC count and temperature do not suggest a dermatologic issue.
2. Contractures: No evidence suggests reduced mobility or positioning problems causing contractures.
3. 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:

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

Rationale for incorrect parameters to monitor:

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

Choice A reason: Substances that change a cell so that it becomes cancerous are potential sources of cancer. Carcinogens are agents that cause genetic mutations or damage to cells, leading to uncontrolled cell growth and the development of cancer. This definition accurately reflects the nature of carcinogens and their role in cancer development.

Choice B reason: Carcinogens are not substances that contain cancerous cells. Instead, they are substances or factors that can induce cancer by causing genetic mutations or cellular damage. The statement is incorrect because it misrepresents the nature of carcinogens.

Choice C reason: While it is true that some carcinogens are present in the environment, the statement that they cannot be avoided is not entirely accurate. Many carcinogens can be avoided or minimized through lifestyle choices, such as avoiding tobacco smoke, reducing exposure to harmful chemicals, and using protective measures against ultraviolet (UV) radiation. The statement is overly deterministic and does not account for preventive measures.

Choice D reason: Environmental factors such as sunlight and chemicals can contribute to the development of cancer, but they do not cause cancer to spread. The spread of cancer (metastasis) occurs when cancer cells break away from the original tumor and travel to other parts of the body. The statement conflates the causes of cancer with the mechanisms of cancer spread, making it inaccurate.