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.

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Correct Answer is C

Explanation

A. Teaching a family member to administer eye drops may be appropriate for some clients undergoing eye surgery, but it is not specifically indicated for retinal detachment repair.
B. Encouraging deep breathing and coughing exercises is important for preventing respiratory complications but is not directly related to postoperative care for retinal detachment repair.
C. Providing an eye shield to be worn while sleeping is important to protect the eye and prevent inadvertent trauma during the vulnerable postoperative period. It helps promote healing and
prevents further injury to the eye.
D. Obtaining vital signs every 2 hours during hospitalization is a general nursing intervention but is not specific to the postoperative care of a client undergoing retinal detachment repair.

A. Connect the nasogastric tube to suction as prescribed. B. Clamp the nasogastric tube and contact the healthcare provider. C. Immediately remove and then reinsert the nasogastric tube. D. Connect the nasogastric tube to high continuous suction.

Correct Answer is B

Explanation

A. Connect the nasogastric tube to suction as prescribed: "Coffee ground" drainage can indicate the presence of blood in the stomach, which requires further assessment before initiating suction.
B. Clamp the nasogastric tube and contact the healthcare provider: Clamping the tube helps
prevent further aspiration of gastric contents, and contacting the healthcare provider is necessary for further evaluation and instructions.
C. Immediately remove and then reinsert the nasogastric tube: While removing and reinserting the tube may be necessary, contacting the healthcare provider for guidance is the priority.
D. Connect the nasogastric tube to high continuous suction: Initiating suction without further evaluation can exacerbate bleeding and is not appropriate without guidance from the healthcare provider.

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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

The nurse is providing care to a client having surgery to repair a retinal detachment to the left eye. Which intervention should the nurse implement during the postoperative period?

Correct Answer is C

Explanation

A client has a prescription for the insertion of a nasogastric tube to low intermittent suction. When inserting the nasogastric tube, the nurse observes an immediate return of "coffee ground" drainage. Which action should the nurse implement?

Correct Answer is B

Explanation

The nurse implements a primary prevention program for sexually transmitted diseases in a nurse managed health center. Which outcome indicates that the program was effective?

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