An older adult client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, what nursing care intervention(s) should the nurse include in the client's plan of care? Select all that apply.

Maintain sequential compression devices while in bed.

Teach client to use incentive spirometer every 2 hours while awake.

Assess pain level and medicate PRN as prescribed.

Remove urinary catheter as soon as possible and encourage voiding.

Administer low molecular weight heparin as prescribed.

Answer and Explanation

Correct Answer : B,D

SCDs are effective for preventing DVT but are not directly related to infection prevention. The focus here is more on preventing respiratory and urinary infections.

B.   Teaching the client to use an incentive spirometer every 2 hours while awake helps prevent
atelectasis and pneumonia by promoting deep breathing and lung expansion, reducing the risk of respiratory infections.
C.   Assessing pain level and medicating PRN as prescribed is important for postoperative comfort but is not directly related to reducing the risk of infection.
D.   Removing the urinary catheter as soon as possible and encouraging voiding helps reduce the risk of urinary tract infections, which are common in clients with prolonged catheter use.
E.   Low molecular weight heparin helps prevent blood clots, reducing the risk of thrombosis, which can increase the risk of postoperative complications, including infections.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","D","E"]

Explanation

A. Loss of sensation to the left lower extremity warrants immediate intervention as it may indicate nerve damage, impaired circulation, or compartment syndrome. These findings require urgent evaluation to prevent permanent damage.

B. Sloughing tissue around wound edges is a common finding in burn injuries during the healing process. While it requires monitoring and proper wound care, it does not necessitate immediate intervention unless accompanied by signs of infection.

C. Weeping serosanguineous fluid from wounds is expected in burn injuries, especially in the early stages of healing. This finding does not indicate an acute complication.

D. Reporting increased pain and pressure is a critical finding as it may indicate compartment syndrome, a condition where increased pressure within a muscle compartment impairs circulation and tissue viability. Immediate intervention is required to prevent further complications.

E. A change in the quality of peripheral pulses is an alarming finding as it suggests impaired circulation, potentially due to edema, vascular compromise, or compartment syndrome. This requires prompt assessment and action to restore adequate blood flow.

A. ambulated 100 yards (91 meters) last night and 200 yards B. pain rating of 2 C. tolerated fluids D. Alert and oriented times 4 E. Voided twice F. Respiratory WNL G. Cardiovascular WNL H. no nausea or vomiting

Correct Answer is ["A","B","C","D","E"]

Explanation

The client has rested well throughout the night with a continuous positive airway pressure (CPAP) device in place. Sequential devices are in place for venous thromboembolism prevention. The client ambulated 100 yards (91 meters) last night and 200 yards (183 meters) this morning. She reports pain rating of 2 on 0 to 10 scale, located in the abdomen, described as aching. She has tolerated fluids throughout the night with no nausea or vomiting.

Assessment

Neurological Alert and oriented times 4.

Cardiovascular WNL

Respiratory WNL

Gastrointestinal/Genitourinary Voided twice throughout night

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

An older adult client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, what nursing care intervention(s) should the nurse include in the client's plan of care? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When caring for a client with full-thickness burns to both lower extremities, what assessment finding(s) warrant immediate intervention by the nurse? Select all that apply.

Correct Answer is ["A","D","E"]

Explanation

Correct Answer is ["A","B","C","D","E"]

Explanation

Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?

The nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?

The nurse is caring for a client with a binge eating disorder. Which goal should the nurse first establish with the client?

Which is the primary goal when planning nursing care for a client with degenerative joint disease (DJD?

While conducting a physical assessment, a client with cirrhosis of the liver reports to the nurse of having had a 5 lb (2.3 kg) weight gain within the last week. Which assessment finding correlates with the client's comment?

The nurse is completing an admission assessment on an older adult client with dehydration, failure to thrive, and who is immobile. The nurse reports to the healthcare provider that the client's right calf is red and swollen. The nurse should suspect which probable cause of these findings?