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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Hydrocortisone: In Addison's disease, there is adrenal insufficiency leading to decreased cortisol production. During times of stress or illness, such as in this case of an acute viral infection, cortisol replacement therapy (such as hydrocortisone) is crucial to supplement the deficient endogenous cortisol production. This helps to manage the client's weakened state and stabilize their condition.
B. Potassium chloride: While the client's potassium level is elevated, indicating hyperkalemia, administering potassium chloride intravenously would exacerbate the hyperkalemia and potentially lead to further complications, such as cardiac arrhythmias.
C. Regular insulin: Regular insulin is indicated for the treatment of hyperglycemia, but the client's glucose level is low, indicating hypoglycemia. Administering regular insulin in this scenario would further decrease the client's blood glucose level, worsening their condition.
D. Broad spectrum antibiotic: While an acute viral infection may predispose the client to secondary bacterial infections, there is no indication from the client's presentation or laboratory values suggesting a need for broad spectrum antibiotics at this time. The priority is addressing
the adrenal crisis and stabilizing the client's condition with appropriate cortisol replacement therapy.
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
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