The nurse will choose the best time to continue postoperative education regarding wound care and dressings, which would be:
immediately after the patient has been medicated for pain.
the last thing in the evening, after visitors have left, before bedtime.
when the patient is comfortable and receptive to the patient education.
just before the patient is discharged, so the information is current.
The Correct Answer is C
A. Immediately after the patient has been medicated for pain.
While pain relief may help, education should be conducted when the patient is alert and comfortable, not immediately after pain medication when they may be drowsy.
B. The last thing in the evening, after visitors have left, before bedtime. Education right before bedtime may not be effective if the patient is tired, as retention and attention may be reduced.
C. When the patient is comfortable and receptive to the patient education.
Teaching should occur when the patient is comfortable, alert, and receptive to ensure they can retain and understand the information.
D. Just before the patient is discharged, so the information is current.
Waiting until discharge could overwhelm the patient, and they may not have time to ask questions or clarify information.
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Correct Answer is D
Explanation
A. While hematocrit levels provide information about blood volume status, they are not directly relevant to infection status or wound healing in burn patients.
B. Blood pH levels can indicate acid-base imbalances, but they do not specifically inform the nurse about the presence of infection.
C. Platelet count is important for assessing coagulation and bleeding risks, but it does not provide direct information regarding infection.
D. White blood cell (WBC) count is critical in assessing for infection, as an elevated WBC count can indicate the presence of an infection, particularly in a client with significant burns who is at increased risk for sepsis.
Correct Answer is B
Explanation
A. Discontinuing the infusion may lead to increased clotting and potential obstruction of the catheter. Continuous bladder irrigation is essential to keep the bladder clear of clots and debris following surgery.
B. Manually irrigating the catheter can help clear any clots that may be obstructing the catheter, ensuring adequate drainage and preventing complications such as bladder distention or retention. This is the most immediate and appropriate action to take in response to the presence of clots.
C. Monitoring catheter drainage is important; however, it does not address the potential issue of clots obstructing the flow of urine, which is the priority concern in this scenario.
D. Decreasing the flow rate may not be beneficial and could lead to inadequate irrigation of the bladder, which could exacerbate clot formation and urinary retention.