Nokea
A nurse is giving a client instructions for showering with special antimicrobial soap the night before surgery. What instruction is most appropriate?
- A. After you wash the surgical site, shave the area with your own razor
- B. Be sure to wash the area where you will have surgery very thoroughly
- C. Use a washcloth to wash the surgical sites, do not take a full shower or bath
- D. Wash the surgical site first, then shampoo and wash the rest of your body
Correct Answer: B
Rationale: The proposed surgical site needs to be washed thoroughly and completely with the antimicrobial soap. Shaving, if absolutely necessary, should be done in the operative suite immediately before the operation begins, using sterile equipment. The client needs a full shower or bath (shower preferred). Washing the surgical site last ensures that soap does not run over the cleansed site if other areas are washed first.
You may also like to solve these questions
A student nurse asks why older adults are at higher risk for complications after surgery. What reasons does the registered nurse give?
- A. Decreased cardiac output
- B. Decreased oxygenation
- C. Frequent nocturia
- D. Mobility issues
- E. Inability to adapt to new surroundings
Correct Answer: A,B,C,D
Rationale: Older adults have many age-related physiologic changes that put them at higher risk of complications after surgery, including decreased cardiac output, decreased oxygenation of tissues, nocturia, and mobility issues. They also have a decreased ability to adapt to new surroundings, but this is not the same as being unable to adapt.
The perioperative nurse manager and the postoperative unit manager are concerned about the increasing number of surgical infections in their hospital. What action by the managers is best?
- A. Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met
- B. Encourage staff on both units to provide peer pressure to adhere to hand hygiene policy
- C. Hold educational meetings with the nursing and surgical staff on infection prevention
- D. Monitor staff on both units for consistent adherence to established hand hygiene practices
Correct Answer: A
Rationale: The SCIP project contains core measures that are mandatory for all surgical clients and focuses on preventing infection, serious cardiac events, and venous thromboembolism. The managers should start by reviewing charts to see if the guidelines of this project were implemented. The other actions may be necessary too, but first the managers need to assess the situation.
A student nurse is caring for clients on the postoperative unit. The student asks the registered nurse why malnutrition can lead to poor surgical outcomes. What responses by the nurse are best?
- A. Malnourished clients will have fragile skin
- B. Malnourished clients always have other problems
- C. Many drugs are bound to protein in the body
- D. Poorer wound healing
- E. Weakness and fatigue are common in malnutrition
Correct Answer: A,C,D,E
Rationale: Malnutrition can lead to poorer surgical outcomes for several reasons, including fragile skin that might break down, altered pharmacokinetics due to protein binding, poorer wound healing, and weakness or fatigue that can interfere with recovery. Malnutrition is not always associated with other comorbidities.
An older client is hospitalized after an operation. When assessing the client for postoperative infection, the nursing physical activity on which assessment?
- A. Change in behavior
- B. Daily white blood cell count
- C. Presence of fever and chills
- D. Tolerance of increasing activity
Correct Answer: A
Rationale: Older people have an age-related decrease in immune system functioning and may not show classic signs of infection such as increased white blood cell count, fever and chills, or obvious localized signs of infection. A change in behavior often signals an infection or onset of other illness in the older client.
A nurse assesses a client in the preoperative holding area and finds brittle nails and hair, dry skin, and muscle wasting. What action by the nurse is best?
- A. Consult the surgeon about a postoperative dietitian referral
- B. Document the findings thoroughly in the client's chart
- C. Encourage the client to eat more after recovering from surgery
- D. Refer the client to Meals on Wheels after discharge
Correct Answer: A
Rationale: This client has signs of malnutrition, which can impact recovery from surgery. The nurse should consult the surgeon about prescribing a consultation with a dietitian in the preoperative period to optimize the client's nutritional status. Documenting findings is important but not sufficient alone. Encouraging the client to eat more may be helpful, but a professional nutritional assessment is needed. Meals on Wheels may not address immediate preoperative needs.