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.
Correct Answer : B,D
A.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
- A) Any level of fever is not necessarily serious after vaccination. Mild fever is a common side effect and can be monitored at home unless it exceeds 101 degrees Fahrenheit or persists beyond 48 hours.
- B) Keeping the child home from daycare is not necessary unless the child develops symptoms that warrant closer observation or care, such as a high fever or behavioral changes.
- C) Aspirin should not be given to children due to the risk of Reye's syndrome, a rare but serious condition that can cause swelling in the liver and brain.
- D) Applying a cool pack to the injection site is a safe and effective way to reduce discomfort and swelling that may occur after the vaccination.
Correct Answer is ["A","E","F"]
Explanation
A. Exercise planning:
Exercise is a cornerstone of diabetes management and can help reduce cardiovascular risk factors.
Regular activity can improve cholesterol levels, particularly by increasing HDL (good cholesterol) and potentially lowering LDL (bad cholesterol).
It can also aid in weight management, which is particularly important for this client with a BMI of 28 kg/m^2.
B. Oral antidiabetic:
While oral antidiabetics are a common treatment, the client's laboratory results do not indicate a current diagnosis of diabetes, thus it may not be necessary at this stage.
C. Short acting insulin:
Short acting insulin is typically used for managing blood sugar levels in individuals with diagnosed diabetes, particularly type 1 or advanced type 2 diabetes.
There is no indication from the client's history or lab results that he requires insulin therapy at this time.
D. Extra carbohydrates:
Adding extra carbohydrates without monitoring blood glucose levels could be detrimental, especially in individuals at risk of developing diabetes.
Carbohydrates need to be carefully balanced in a diabetic diet, and the client has not been diagnosed with diabetes.
E. Nutrition education:
Education on nutrition can help the client make informed food choices to manage both blood sugar and cholesterol levels.
It can also provide guidance on portion control, which can contribute to weight management.
F. Weight reduction treatment:
Given the client's overweight status, a weight reduction plan could help lower the risk of developing diabetes.
Weight loss can also have a positive impact on cholesterol levels and overall metabolic health.
G Long acting insulin:
Long acting insulin is used to manage blood sugar levels throughout the day and is typically prescribed for individuals with diagnosed diabetes.
As with short acting insulin, there is no current indication for insulin therapy for this client.
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