The nurse assesses the following data from a patient with diabetes mellitus who is 4 days postoperative for repair of an abdominal aortic aneurysm. Which assessment finding is of greatest concern for the nurse?

Correct Answer: B

Rationale: The correct answer is B: Temperature 38.5o C (101.4o F). A postoperative patient with diabetes mellitus is at higher risk for infection due to impaired immune function. A temperature of 38.5o C indicates a possible infection, which is concerning postoperatively. High fever can indicate sepsis, a life-threatening condition. A: Vesicular breath sounds in the lung bases are normal lung sounds and not indicative of immediate concern in this scenario. C: Incisional pain rating of 6 out of 10 is expected postoperatively and can be managed with appropriate pain medication. D: Blood glucose of 164 mg/dL is slightly elevated but not the primary concern in this postoperative patient with diabetes mellitus.

Correct Answer: C

Rationale: The correct answer is C. The nurse should identify the patient by name and date of birth on the patient's wristband and match it to the medication order. This is crucial for patient safety to ensure the right medication is given to the right patient. Matching the patient's information on the wristband with the medication order helps prevent medication errors. Option A only identifies the patient by name and room number, which may not be sufficient to ensure accuracy. Option B focuses on the room and bed number, which is less critical than confirming the patient's identity. Option D relies solely on asking the patient for their name, which is not as reliable as checking the wristband. Matching the patient's information on the wristband is the best practice to prevent medication errors and ensure patient safety.

Correct Answer: D

Rationale: The correct order of events when applying PPE is crucial for infection control. Starting with handwashing removes potential contaminants. Gowning before mask and eye protection prevents contamination of the face. Eye protection comes before gloves to avoid self-contamination. Gloves are the last item to be put on to minimize the risk of touching contaminated surfaces. Therefore, the correct order is handwashing, gown, mask, eye protection, and gloves. Other choices are incorrect because they do not follow the proper sequence for maximum protection.

Correct Answer: B

Rationale: Correct Answer: B Rationale: 1. The tray is considered unsterile if a blood-soaked gauze from the patient is placed back onto it. 2. This action contaminates the tray, breaking the sterile field integrity. 3. Maintaining sterile technique is crucial to prevent infections during surgery. 4. Any breach in sterility increases the risk of introducing harmful microorganisms. 5. Therefore, ensuring that contaminated items are not placed back on the sterile field is essential. Summary: - Choice A is incorrect as only the center of a sterile field is considered sterile, not the edges. - Choice C is incorrect as the skin cannot be made completely sterile, but it should be cleaned and disinfected. - Choice D is incorrect as any instrument that is held out of view should not be considered sterile due to potential contamination risks.

Correct Answer: A

Rationale: The correct answer is A: Pad bed side rails. This precaution is important because during a seizure, the client may thrash about and could potentially injure themselves by hitting the bed rails. Padding the bed side rails can help prevent injuries. B: Placing a pillow under all extremities is not necessary and may not provide any significant benefit in preventing injuries during a seizure. C: Elevating the bed to a high position is not relevant to preventing injuries during a seizure and may not be practical in this situation. D: Ensuring oxygen access is important in general emergency care, but it is not specifically related to preventing injuries during a seizure.