The nurse identifies which of the following as one of the primary nursing interventions for preventing surgical site infection?

Having the patient splint their incision site when coughing and deep breathing

Offering around the clock pain medication the immediate post operative phase

Administering prescribed pre-operative antibiotics within 30-60 minutes of surgery.

Performing the first dressing change on a new surgical site in the post operative setting

Answer and Explanation

The Correct Answer is C

A. Having the patient splint their incision site when coughing and deep breathing:
While splinting the incision site can help alleviate pain and prevent strain on the surgical wound during coughing and deep breathing, it is not a primary intervention for preventing surgical site infection. Infection prevention is more directly related to sterile technique, antibiotic prophylaxis, and maintaining a clean environment around the wound. Splinting can support postoperative recovery, but it does not directly prevent infection.

B. Offering around the clock pain medication in the immediate post-operative phase:
Providing pain medication is important for patient comfort and to facilitate early mobilization after surgery. However, pain management does not directly prevent surgical site infections. The focus for infection prevention lies in maintaining sterility, administering antibiotics as prescribed, and appropriate wound care rather than pain control alone.

C. Administering prescribed pre-operative antibiotics within 30-60 minutes of surgery:
The administration of prophylactic antibiotics before surgery, typically within 30-60 minutes of the incision, is a primary intervention for preventing surgical site infections (SSIs). This timing ensures that the antibiotics are at therapeutic levels in the bloodstream when the surgical procedure begins, reducing the risk of introducing bacteria into the surgical site. This is a well-established guideline for infection prevention in surgical settings.

D. Performing the first dressing change on a new surgical site in the postoperative setting:
The first dressing change should generally be done by a healthcare professional using sterile technique. However, the timing and handling of the first dressing change are more related to wound care practices rather than a primary strategy for preventing infection. Infection prevention primarily involves proper antibiotic prophylaxis, maintaining a sterile field, and managing the surgical site during the early post-operative period. The first dressing change, while important for wound healing, is not the most immediate or primary intervention for preventing surgical site infection.

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Correct Answer is C

Explanation

A) "Complete blood count (CBC)":
. A CBC can provide important information about the patient's overall health, including potential signs of infection, anemia, or other underlying conditions. However, in the context of acute neurological symptoms such as left-sided weakness, CT scan is the priority test because it will help quickly determine if there is an acute neurological event, such as a stroke or hemorrhage. While a CBC might be useful later to assess for underlying
conditions or potential causes, it is not the first test to perform in this scenario.

B) "Electroencephalogram (EEG)":
. An EEG is primarily used to diagnose and assess seizure activity or epileptic disorders. While seizures can cause neurological deficits, the patient's sudden onset of left-sided weakness is more suggestive of a stroke, not a seizure. The priority is to rule out stroke with a CT scan, not to assess for seizures with an EEG.

C) "Computed tomography (CT) scan":
. A CT scan is the first diagnostic test to perform in patients with acute neurological deficits such as sudden-onset weakness, especially when a stroke is suspected. A CT scan can quickly detect if the cause is an ischemic stroke (lack of blood flow due to a clot) or a hemorrhagic stroke (bleeding in the brain). Time is critical in the management of stroke, as early intervention with treatments like tPA (tissue plasminogen activator) for ischemic stroke can greatly improve outcomes. The CT scan can help determine if the patient is a candidate for thrombolysis or if other interventions are needed.

D) "Chest radiograph (chest x-ray)":
. While a chest x-ray can be useful for diagnosing respiratory issues, such as pneumonia or congestion, it is not helpful in evaluating the cause of acute neurological symptoms like left-sided weakness. The priority test is a CT scan to evaluate the brain and rule out conditions like stroke or hemorrhage, not a chest x-ray.

A. I will notify my doctor before taking any other medications’’ B. "I should talk to my doctor about other methods of contraception in addition to my current oral contraceptives. C. "I'll be glad when I can stop taking this medicine after my seizures are controlled’’ D. I have made an appointment to see my dentist next week.’’

Correct Answer is C

Explanation

A) "I will notify my doctor before taking any other medications:"
Phenytoin interacts with many medications, both prescription and over-the-counter. It is crucial for the client to inform their doctor before starting any new medications, including herbal supplements, as phenytoin may have significant drug interactions that could alter its effectiveness or increase the risk of side effects.

B) "I should talk to my doctor about other methods of contraception in addition to my current oral contraceptives:"
Phenytoin can decrease the effectiveness of oral contraceptives, leading to an increased risk of unintended pregnancy. It is important for clients to discuss alternative or additional methods of contraception, such as non-hormonal methods or alternative hormonal birth control, with their healthcare provider to prevent pregnancy while taking phenytoin.

C) "I'll be glad when I can stop taking this medicine after my seizures are controlled:"
Phenytoin is typically a lifelong medication for managing seizures, even if the seizures are well-controlled. Stopping the medication without a doctor's approval can lead to seizure recurrence. Seizure control does not always mean stopping medication, and clients need to understand the importance of continuing the prescribed treatment regimen, even after achieving stability.

D) "I have made an appointment to see my dentist next week:"
Phenytoin can cause gingival hyperplasia, which increases the need for regular dental checkups. It is recommended that clients taking phenytoin see a dentist regularly to manage this potential side effect and maintain oral health.

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The nurse identifies which of the following as one of the primary nursing interventions for preventing surgical site infection?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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