The nurse is caring for a client after surgery. Which finding should the nurse prioritize to identify a surgical site infection (SSI)?

Nausea

Fever

Poor appetite

Pain

Answer and Explanation

The Correct Answer is B

A. Nausea: Nausea may occur after surgery due to anesthesia or medications, but it is a nonspecific symptom and does not directly indicate infection. It is important to monitor but is not the priority for identifying an SSI.

B. Fever: Fever is an early and objective sign of systemic infection, including surgical site infection. Elevated temperature indicates the body’s inflammatory response to microbial invasion at the wound site and warrants prompt assessment of the surgical area.

C. Poor appetite: Reduced appetite is common postoperatively and can result from pain, medications, or stress. While it may accompany infection, it is nonspecific and not the most critical indicator of SSI.

D. Pain: Some pain at the surgical site is expected after surgery. Increased or unrelieved pain may signal complications, including infection, but fever provides a more objective and early indication that infection may be developing.

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Correct Answer is C

Explanation

A. Open the sterile drape and place it on the table: Opening sterile supplies before preparing the environment increases the risk of contamination. The surface must be clean, dry, and positioned appropriately before any sterile items are opened. Environmental preparation precedes establishing the sterile field.

B. Put on sterile personal protective equipment: Sterile gloves and PPE are donned after the sterile field is set up, not before. Donning them too early increases the risk of contamination during setup. Hand hygiene and environment preparation come first.

C. Clean a work surface and raise it to waist level: The work surface must be disinfected and positioned at or above waist level to maintain visibility and prevent contamination. Sterile fields kept below waist level are considered contaminated. Preparing the environment is the first step in sterile setup.

D. Arrange sterile instruments on the sterile field: Sterile instruments are handled only after the sterile field has been properly established. Placing instruments occurs later in the setup sequence. This action depends on prior preparation of the field.

A. "I will encourage him to walk daily so his muscles get stronger." B. "I will ensure he inserts his dentures so he can eat well during the day." C. "I will remind him to shift in his chair at least every two hours." D. "I will change his incontinence brief about every eight hours or so."

Correct Answer is D

Explanation

A. "I will encourage him to walk daily so his muscles get stronger.": Ambulation improves circulation, reduces prolonged pressure on bony prominences, and supports muscle strength needed for repositioning. Regular movement is a key preventive strategy for pressure injury development. Mobility also enhances overall skin integrity.

B. "I will ensure he inserts his dentures so he can eat well during the day.": Adequate nutrition supports tissue repair, immune function, and skin resilience. Proper denture use promotes sufficient caloric and protein intake. Nutrition is a foundational component of pressure injury prevention.

C. "I will remind him to shift in his chair at least every two hours.": Regular repositioning redistributes pressure and restores capillary blood flow to compressed tissues. While chair-bound clients often benefit from more frequent shifts, this practice still reflects appropriate preventive awareness. Pressure relief is essential for skin protection.

D. "I will change his incontinence brief about every eight hours or so.": Prolonged moisture exposure from urine or stool increases skin maceration and susceptibility to breakdown. Incontinence care requires frequent brief changes and prompt skin cleansing. Moisture management is critical in preventing pressure injuries.

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The nurse is caring for a client after surgery. Which finding should the nurse prioritize to identify a surgical site infection (SSI)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse plans to perform a sterile procedure on a client at the bedside. Which action should the nurse plan to take first when setting up their sterile field?

Correct Answer is C

Explanation

The nurse provided discharge teaching to the client's family on preventing pressure injuries at home. Which statement made by the family member indicates a need for further instruction?

Correct Answer is D

Explanation

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