Which patient is most at risk for developing an infection?

A patient who is recovering from a right total hip surgery

A patient who has been admitted for stabilization of heart problems

A patient who has been admitted with dehydration

A patient who is in observation for chest pain

Answer and Explanation

The Correct Answer is A

Choice A reason: Hip surgery involves invasive procedures, increasing infection risk due to surgical wounds, immobility, and potential hardware. This patient faces higher risk than others, making it the correct choice.

Choice B reason: Heart problem stabilization may involve catheters, but surgical wounds pose a greater infection risk. Cardiac patients are less prone to immediate infection unless invasive devices are present, making this less likely.

Choice C reason: Dehydration weakens immunity but is less directly linked to infection than surgical wounds. Hydration correction reduces risk, making this patient less at risk than the surgical patient.

Choice D reason: Chest pain observation typically involves non-invasive monitoring, with lower infection risk than surgery. Without invasive procedures, this patient is less susceptible, making this incorrect.

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Correct Answer is B

Explanation

Choice A reason: Administering diphenhydramine treats allergic symptoms but does not address the ongoing transfusion reaction. Stopping the transfusion prevents further allergen exposure, making this a secondary action.

Choice B reason: Stopping the transfusion is the first action, as itching and hives indicate an allergic reaction. Halting the infusion prevents worsening symptoms, like anaphylaxis, making this the priority intervention.

Choice C reason: Notifying the provider is necessary but follows stopping the transfusion. Ceasing the infusion immediately mitigates the reaction, ensuring patient safety, making notification a subsequent step.

Choice D reason: Obtaining vital signs provides data but delays addressing the reaction. Stopping the transfusion halts allergen administration, taking precedence over assessment, making this a secondary action.

A. Pain medication administration B. Poor nutritional state C. Obesity D. Altered mental state E. Wound infection

Correct Answer is ["B","C","E"]

Explanation

Choice A reason: Pain medication administration does not directly contribute to dehiscence, which results from mechanical stress or poor healing. While pain control is important, it is not a primary risk factor compared to nutrition, obesity, or infection, making this incorrect.

Choice B reason: Poor nutritional state is a risk factor for dehiscence, as inadequate protein and vitamins impair collagen synthesis, weakening wound closure. Malnutrition delays healing, increasing the risk of incision separation under stress, making this a correct factor to include.

Choice C reason: Obesity increases dehiscence risk due to excessive tension on incisions from adipose tissue, poor vascularity, and higher infection rates. This mechanical and physiological stress compromises wound integrity, making it a correct factor to include in teaching.

Choice D reason: Altered mental state is not a direct risk factor for dehiscence, though it may affect compliance with activity restrictions. Physical factors like infection or obesity have a stronger impact on wound healing, making this incorrect.

Choice E reason: Wound infection is a key risk factor for dehiscence, as bacterial activity weakens tissue and disrupts healing, causing incision breakdown. These compromises wound integrity, making it a critical factor to include in teaching about surgical complications.

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Which patient is most at risk for developing an infection?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving a blood transfusion. The client reports itching and hives. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is teaching a newly licensed nurse about the risk factors for dehiscence for surgical clients who have surgical incisions. Which of the following should the nurse include? (Select all that apply)

Correct Answer is ["B","C","E"]

Explanation

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