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 B

Explanation

A) Obtaining a primary and secondary tubing set:
The primary tubing is used for the intravenous access, and the secondary tubing is attached for administering the blood product. This ensures that the blood transfusion will be delivered effectively, and it is a standard practice to use proper IV tubing for blood products to avoid contamination or complications.

B) Ensuring another licensed personnel is available:
. While it is required that two licensed healthcare professionals verify the blood product before starting the transfusion, this action itself is not contraindicated, it is required. Both individuals should independently check the patient's identification, blood type, and the matching of the blood product before administration. Therefore, the answer to the question should not be about ensuring availability of licensed personnel as this is actually a required safety measure, not contraindicated. The actual contraindications involve actions like using inappropriate fluids for transfusion or mismatching blood.

C) Obtaining 0.9% normal saline solution:
This is appropriate and necessary when preparing for a blood transfusion. Normal saline (0.9%) is the only compatible solution that should be used to flush the IV line before and after the transfusion or to prime the blood tubing. Other solutions, such as lactated Ringer's, can cause clotting when mixed with blood, making saline the only appropriate choice.

D) Checking ABO and Rh status of the donor and recipient:
This is essential and mandatory before administering a blood transfusion. It is critical to ensure that the ABO blood group and Rh factor of the donor and recipient are compatible to prevent hemolytic reactions. This compatibility check must be done every time before administering a transfusion, and it is an integral part of ensuring patient safety.

A. Positive Trousseau's sign B. Hypertension and headache C. Tachycardia and tachypnea D. Depressed deep tendon reflexes and lethargy

Correct Answer is D

Explanation

A. Positive Trousseau's sign:
A positive Trousseau's sign (spasms of the hand and forearm when a blood pressure cuff is inflated) is a sign of hypocalcemia, not hypermagnesemia. It indicates low calcium levels in the blood, not elevated magnesium levels. Therefore, this is not indicative of hypermagnesemia.

B. Hypertension and headache:
Hypertension and headache are more commonly associated with hypomagnesemia (low magnesium levels), rather than hypermagnesemia. Elevated magnesium levels tend to cause vasodilation, which can lead to hypotension, not hypertension. Therefore, these symptoms are not consistent with hypermagnesemia.

C. Tachycardia and tachypnea:
Tachycardia and tachypnea are often signs of hypomagnesemia as well, where the body compensates for low magnesium by increasing heart rate and breathing rate. Hypermagnesemia, on the other hand, usually causes bradycardia (slowed heart rate) and respiratory depression. So, tachycardia and tachypnea are not indicative of hypermagnesemia.

D. Depressed deep tendon reflexes and lethargy:
This is the correct answer. Hypermagnesemia can lead to depressed deep tendon reflexes (DTRs) and lethargy, as magnesium is a central nervous system depressant. Elevated magnesium levels inhibit neuromuscular function, which can cause symptoms such as diminished reflexes, muscle weakness, and overall lethargy or drowsiness. This combination of findings is a key indicator of hypermagnesemia.

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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

The nurse is preparing for a blood transfusion. Which of the following would be contraindicated to include in the prep for the procedure?

Correct Answer is B

Explanation

A nurse is monitoring a client receiving an infusion of IV magnesium sulfate. Which of the following findings would indicate to the nurse that the client isexperiencing hypermagnesemia?

Correct Answer is D

Explanation

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