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 A

Explanation

A. Informing the client that gradual tapering must be used to discontinue the medication is crucial because abruptly stopping antidepressants can lead to withdrawal symptoms or the return of depressive symptoms. This response acknowledges the client’s concerns and provides a safe approach to discontinuation.

B. While side effects may diminish over time for some individuals, this response does not address the client's concerns or provide guidance on how to manage the side effects.
C. Reminding the client that feeling better is the therapeutic effect of the medication does not address the client's concerns about side effects or desire to discontinue the medication.

D. While discussing side effects with the healthcare provider is important, it does not address the need for a safe discontinuation process, which is why gradual tapering should be emphasized first.

A. Have the client breathe into a paper bag. B. Ask the client to take short, rapid breaths. C. Instruct the client in pursed lip breathing. D. Increase oxygen to three L/minute.

Correct Answer is C

Explanation

A. Having the client breathe into a paper bag is a technique sometimes used for anxiety-induced hyperventilation but is not appropriate for a client with chronic obstructive lung disease experiencing shortness of breath. It can lead to a buildup of carbon dioxide, worsening the client's condition.
B. Asking the client to take short, rapid breaths may exacerbate hyperventilation and increase the client's anxiety. This breathing pattern can lead to further respiratory distress in a client with
chronic obstructive lung disease.
C. Instructing the client in pursed lip breathing is the most appropriate action. Pursed lip breathing helps to prolong exhalation, reduce air trapping, and improve gas exchange in clients with chronic obstructive lung disease. It can help alleviate shortness of breath and promote relaxation.
D. Increasing oxygen to three L/minute may not be necessary and could potentially lead to oxygen toxicity. The priority is to help the client manage their shortness of breath effectively through breathing techniques.

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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

Correct Answer is A

Explanation

A client with chronic obstructive lung disease who is receiving oxygen at 1.5 L/minute by nasal cannula is currently short of breath. Which action should the nurse take?

Correct Answer is C

Explanation

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