While changing a client’s postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider (HCP), the nurse should note which of the client’s laboratory values?

Culture and sensitivity

C-reactive protein level

Serum blood glucose level

Blood pH level

Answer and Explanation

The Correct Answer is A

Choice A reason: Culture and sensitivity identify the causative organism and antibiotic susceptibility of purulent drainage, indicating a wound infection. This guides targeted antimicrobial therapy, as postoperative infections may involve resistant bacteria like MRSA, ensuring effective treatment and preventing complications like sepsis or delayed healing.

Choice B reason: C-reactive protein indicates systemic inflammation but is non-specific for wound infections. Purulent drainage requires pathogen identification via culture to guide therapy. While elevated CRP may support infection suspicion, it does not direct antibiotic choice, making it less critical than culture results.

Choice C reason: Serum blood glucose is relevant for wound healing, as hyperglycemia impairs immune response, but it does not identify the infection’s cause. Purulent drainage requires microbiological data from culture to select antibiotics, making glucose levels secondary for immediate infection management.

Choice D reason: Blood pH level assesses acid-base balance, irrelevant to localized wound infection. Purulent drainage indicates bacterial infection, requiring culture to identify pathogens. pH may be altered in systemic sepsis, but culture is the priority for guiding therapy in postoperative wound infections.

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Correct Answer is C

Explanation

Choice A reason: Rinsing the mouth after ipratropium use is unnecessary, as this anticholinergic bronchodilator does not cause oral candidiasis like corticosteroids. However, it is not harmful and does not indicate misunderstanding of critical administration technique. This action is less concerning than incorrect priming, which affects drug delivery.

Choice B reason: Attaching a spacer to the ipratropium inhaler is appropriate, as it improves drug delivery to the lungs by reducing oropharyngeal deposition. This enhances bronchodilation in COPD by ensuring more medication reaches the airways, indicating correct understanding and requiring no additional teaching.

Choice C reason: Priming the inhaler with 7 pumps is excessive and incorrect. Ipratropium inhalers typically require 2–3 priming sprays if unused for 24 hours. Over-priming wastes medication, reducing doses available for bronchodilation, and indicates a need for teaching to ensure proper administration for COPD management.

Choice D reason: Storing ipratropium at room temperature is correct, as extreme heat or cold can degrade the canister’s propellant, impairing drug delivery. This action shows understanding of proper storage to maintain the inhaler’s efficacy, requiring no further teaching for effective COPD treatment.

A. Lay down on each side with knees bent and breathe from abdomen B. Increase breathing rate for a full 30 seconds C. Draw air in through nose and exhale slowly through pursed lips D. Raise hands above the head to expand the diaphragm

Correct Answer is A

Explanation

Choice A reason: Lying on each side with abdominal breathing may aid relaxation but does not optimize gas exchange in emphysema. Pursed-lip breathing better maintains airway pressure, preventing alveolar collapse, which is critical for improving oxygenation and CO2 elimination in COPD.

Choice B reason: Increasing breathing rate for 30 seconds causes hyperventilation, worsening CO2 retention in emphysema by reducing effective tidal volume. This exhausts respiratory muscles, impairing gas exchange, making it counterproductive compared to pursed-lip breathing, which enhances alveolar ventilation.

Choice C reason: Pursed-lip breathing, inhaling through the nose and exhaling slowly through pursed lips, maintains positive airway pressure, preventing alveolar collapse in emphysema. This improves gas exchange by enhancing oxygenation and CO2 removal, making it the most effective instruction for dyspnea relief.

Choice D reason: Raising hands above the head may stretch the chest but does not address emphysema’s airflow limitation. It can strain respiratory muscles, worsening dyspnea, unlike pursed-lip breathing, which directly improves alveolar ventilation and gas exchange, making this choice ineffective.

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While changing a client’s postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider (HCP), the nurse should note which of the client’s laboratory values?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of chronic obstructive pulmonary disease (COPD) receives a new prescription for an ipratropium inhaler. Which action indicates to the nurse that additional teaching is needed?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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