An older adult client is admitted for the repair of a broken hip. To reduce the risk of infection in the postoperative period, which nursing care interventions should the nurse include in the client's plan of care? Select all that apply.
Teach the client to use an incentive spirometer every 2 hours while awake.
Administer low molecular weight heparin as prescribed.
Assess the pain level and medicate as needed, as prescribed.
Maintain sequential compression devices while in bed.
Remove the urinary catheter as soon as possible and encourage voiding.
Correct Answer : A,E
The correct answer is: A. Teach the client to use an incentive spirometer every 2 hours while awake and E. Remove the urinary catheter as soon as possible and encourage voiding.
Choice A reason:
Teaching the client to use an incentive spirometer every 2 hours while awake helps prevent postoperative pulmonary complications such as pneumonia. This intervention promotes lung expansion and clears secretions, reducing the risk of infection.
Choice B reason:
Administering low molecular weight heparin as prescribed is important for preventing deep vein thrombosis (DVT) and pulmonary embolism, but it does not directly reduce the risk of infection.
Choice C reason:
Assessing the pain level and medicating as needed is crucial for patient comfort and mobility, but it does not directly address infection prevention. Effective pain management can indirectly support recovery by enabling better mobility and respiratory function.
Choice D reason:
Maintaining sequential compression devices while in bed is aimed at preventing DVT, not infections. These devices help improve blood circulation and reduce the risk of blood clots.
Choice E reason:
Removing the urinary catheter as soon as possible and encouraging voiding reduces the risk of catheter-associated urinary tract infections (CAUTIs). Prompt removal of the catheter minimizes the duration of exposure to potential pathogens, thereby reducing infection risk.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"C"}
Explanation
Choice A Reason: Hypoglycemia refers to low blood sugar levels, typically below 70 mg/dL (3.9 mmol/L). The client’s fasting blood glucose level is 122 mg/dL (6.8 mmol/L), which is above the normal range, thus ruling out hypoglycemia.
Choice B Reason: Diabetes mellitus is diagnosed when the fasting blood glucose level is 126 mg/dL (7 mmol/L) or higher on two separate tests1. The client’s level is slightly below this threshold, suggesting that he does not currently have diabetes mellitus but is at risk.
Choice C Reason: Prediabetes is indicated by a fasting blood glucose level of 100 to 125 mg/dL (5.6 to 6.9 mmol/L)1. The client’s level falls within this range, indicating that he has higher than normal blood glucose levels but not high enough to be classified as diabetes, hence prediabetes.
Choice D Reason: Gestational diabetes occurs during pregnancy and is not applicable to this male client.
Option i Reason: Fatty liver disease is not directly indicated by the laboratory results provided and is typically associated with elevated liver enzymes and imaging findings.
Option ii Reason: Occupational factors are not directly related to the fasting blood glucose levels.
Option iii Reason: Lack of insulin production is a characteristic of type 1 diabetes, which is not indicated by the client’s fasting blood glucose level alone.
Option iv Reason: Impaired glucose tolerance is a condition where blood glucose levels are higher than normal but not high enough to be classified as diabetes. It is a characteristic of prediabetes and is indicated by the client’s fasting blood glucose level.
Correct Answer is B
Explanation
Choice A reason: Glaucoma is not directly related to the administration of lidocaine, as it does not affect intraocular pressure or the pathophysiology of glaucoma.
Choice B reason: Heart block is a type of arrhythmia where the electrical signal is delayed or blocked entirely. Since lidocaine affects cardiac conduction, it is crucial to review the medical record for heart block before administration.
Choice C reason: Gastric ulcers are not typically a concern when administering lidocaine, as it does not have gastrointestinal effects when given parenterally.
Choice D reason: Diabetes mellitus is not a contraindication for lidocaine administration; however, monitoring blood glucose levels is always important in diabetic patients receiving any medication.
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