Page 504 - Saunders Comprehensive Review For NCLEX-RN

132. Answer: 3

Rationale: Antiplatelets alter normal clotting factors and increase the risk of
bleeding after surgery. Aspirin has properties that can alter platelet aggregation and
should be discontinued at least 48 hours before surgery. However, the client should
always check with his or her surgeon regarding when to stop taking the aspirin
when a surgical procedure is scheduled. Options 1, 2, and 4 are accurate client
statements.
Test-Taking Strategy: Note the strategic words, needs additional teaching. These
words indicate a negative event query and that you need to select the incorrect
client statement. Eliminate options 1 and 2 first because they are comparable or
alike. From the remaining options, recalling that aspirin has properties that can alter
platelet aggregation will direct you to the correct option.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Foundations of Care: Perioperative Care
Health Problem: Adult Health: Musculoskeletal: Rheumatoid Arthritis and
Osteoarthritis
Priority Concepts: Client Education; Clotting
Reference: Ignatavicius, Workman, Rebar (2018), pp. 241-242.

133. Answer: 2

Rationale: Serous drainage is an expected finding at a surgical site. The other
options indicate signs of wound infection. Signs and symptoms of infection include
warm, red, and tender skin around the incision. Wound infection usually appears 3
to 6 days after surgery. The client also may have a fever and chills. Purulent material
may exit from drains or from separated wound edges. Infection may be caused by
poor aseptic technique or a contaminated wound before surgical exploration;
existing client conditions such as diabetes mellitus or immunocompromise may
place the client at risk.
Test-Taking Strategy: Focus on the subject, normal findings in the postoperative
period. Eliminate options 1, 3, and 4 because they are comparable or alike and are
manifestations of infection.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Foundations of Care: Perioperative Care
Health Problem: Adult Health: Integumentary: Wounds
Priority Concepts: Infection; Tissue Integrity
Reference: Ignatavicius, Workman, Rebar (2018), pp. 281-282.

134. Answer: 1

Rationale: Increasing restlessness is a sign that requires continuous and close
monitoring because it could indicate a potential complication such as hemorrhage,

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