Exam 2 Med Surg (Passed!)

The nurse assesses a surgical patient the morning of the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate? a. Obtain wound cultures. b. Document the assessment. c. Notify the health care provider. d. Assess the wound every 2 hours correct answers Answer: B Rationale: The incisional redness and warmth are indicators of the normal initial (inflammatory) stage of wound healing by primary intention. A 24-year-old patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8° F (38.7° C). Which action by the nurse is most appropriate? a. Apply a cooling blanket. b. Notify the health care provider. c. Give the prescribed PRN aspirin (Ascriptin) 650 mg. d. Check the patient's oral temperature again in 4 hours. correct answers Answer: D Rationale: Mild to moderate temperature elevations (less than 103° F) do not harm the young adult patient and may benefit host defense mechanisms. The nurse should continue to monitor the temperature. Antipyretics are not indicated unless the patient is complaining of fever-related symptoms. There is no need to notify the patient's health care provider or to use a cooling blanket for a moderate temperature elevation. Which nursing action is most likely to detect early signs of infection in a patient who is taking immunosuppressive medications? a. Monitor white blood cell count. b. Check the skin for areas of redness. c. Check the temperature every 2 hours. d. Ask about fatigue or feelings of malaise. correct answers Answer: D Rationale: Common clinical manifestations of inflammation and infection are frequently not present when patients receive immunosuppressive medications. The earliest manifestation of an infection may be "just not feeling well." When evaluating the response to treatment for a patient with a fluid imbalance, the most important assessment to include is a. skin turgor. b. presence of edema. c. hourly urine output. d. daily weight. correct answers Answer: D Rationale: Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age. Considerable excess fluid volume may be present before fluid moves into the interstitial space and causes edema. Hourly urine outputs do