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Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise as well as pain with redness at the surgical site. Which action is most appropriate?
- A. Documenting the findings and continuing to monitor the patient
- B. Administering antipyretics and contacting the provider for an antibiotic prescription
- C. Increasing the frequency of assessment to every hour and notifying the patient's primary care provider
- D. Obtaining a wound culture and increasing the frequency of wound care
Correct Answer: A
Rationale: The assessment findings are normal for this stage of healing following surgery. The patient is in the inflammatory phase of the healing process, which involves a response by the immune system. This acute inflammation is characterized by pain, heat, redness, and swelling at the site of the injury (surgery, in this case). The patient also has a generalized body response, including a mildly elevated temperature, leukocytosis, and generalized malaise.
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The nurse has 10 minutes before having to leave the room and administer blood to another patient. Which intervention is the priority for Sam?
- A. Sitting quietly with Sam
- B. Contacting Sam's partner and providing an update
- C. Consulting wound care for a thorough assessment
- D. Hanging the prescribed antibiotic
Correct Answer: D
Rationale: Hanging the prescribed antibiotic is the priority intervention given the diagnosed osteomyelitis, a serious bone infection requiring prompt treatment to prevent further complications. This takes precedence over emotional support, family updates, or wound care consultation within the 10-minute timeframe.
A nurse on a surgical unit works with a student nurse discussing various stages phases of healing for postoperative patients. Which statements accurately describe these stages? Select all that apply.
- A. Hemostasis occurs immediately after an initial injury.
- B. A fluid called exudate is formed in during the proliferation phase.
- C. White blood cells migrate to the wound site during the inflammatory phase.
- D. Granulation tissue forms new tissue in the inflammatory phase.
- E. During the inflammatory phase, patients have generalized bodily responses.
- F. A scar forms in the proliferation phase.
Correct Answer: C,F
Rationale: Hemostasis occurs immediately after an initial injury, with exudate forming during this phase as blood plasma and blood components leak into the area of injury area. White blood cells, mostly including leukocytes and white blood cells, migrate to the wound site during the inflammatory phase to clear ingest bacteria or debris and cellular debris. During this inflammatory phase, the patient experiences a generalized bodily response including a slight fever mildly elevated temperature, increased WBC leukocytosis (increased number of leukocytes in the blood), or generalized malaise. New granulation tissue forms the basis for scar tissue during the proliferation phase. New tissue collagen continues to be laid down deposited in the maturation phase, forming a scar.
A postoperative patient who has a large abdominal incision suddenly calls out for help, shouting, 'Something is falling out of my incision!' The nurse notes the wound is gaping open with tissue bulging outward. Place the nursing interventions in the order they should be performed, arranged from first to last.
- A. Notify the health care provider of the situation.
- B. Cover exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution.
- C. Place the patient in the low Fowler position.
- D. Document the findings and outcome of interventions.
- E. Maintain NPO status for return to the OR for repair.
Correct Answer: C,B,A,E,D
Rationale: The correct order of nursing interventions for this postoperative emergency is to place the patient in the low Fowler position (to prevent further damage or protrusion from increased intraabdominal pressure), cover exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution (to protect the wound), and notify the surgical site of the situation (to address the problem issue, likely requiring with surgery). The patient must be kept NPO for prompt surgical repair will be needed. After the patient has received attention, the nurse should document all assessments and interventions performed in a timely manner.
Based on the objective and subjective assessment of this patient, which priority problem should the nurse identify to guide the plan of care?
- A. Altered skin integrity based on the nonhealing, chronic wounds
- B. Bathing/hygiene ADL deficit based on the rash in the skin folds
- C. Chronic low self-esteem based on their expression of feelings
- D. Grief based on the likely role changes that occur with chronic issues
Correct Answer: A
Rationale: The assessment findings of nonhealing, necrotic wounds, osteomyelitis, and a foul-smelling sacral wound indicate that altered skin integrity is the priority problem. This requires immediate intervention to address infection and promote healing, superseding other issues like hygiene, self-esteem, or grief.
A nurse on a surgical unit has assessed and documented a patient's wound and drainage. Which statements most accurately describe the characteristic of the wound drainage?
- A. Sanguineous drainage is composed of the clear portion of the blood and serous membranes.
- B. Sanguineous drainage is composed of a large number of red blood cells and looks like blood.
- C. Sanguineous drainage is composed of white blood cells, dead tissue, and bacteria.
- D. Sanguineous drainage is thin, cloudy, and watery and may have a musty or foul odor.
Correct Answer: B
Rationale: Sanguineous drainage consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. Serous drainage, generally watery, is composed primarily of the clear, serous portion of the blood and serous membranes. Purulent drainage is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. It is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism.