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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Related Questions
Correct Answer is A
Explanation
Choice A reason: The immediate safety of the client is at risk. A person with dementia who is missing poses a potential danger to themselves due to confusion and the inability to navigate safely in their environment.
Choice B reason: While medication adherence is important for a client with schizophrenia, it does not present an immediate life-threatening situation. The nurse can return this call after addressing more urgent safety concerns.
Choice C reason: Physical altercations at school are serious, but if the child is safe and not in immediate danger, this call can be returned following more urgent issues.
Choice D reason: Sexual dysfunction can significantly affect quality of life, but it is not an immediate safety concern. This call should be returned after more urgent calls have been addressed.
Correct Answer is A
Explanation
Choice A reason:When a client expresses concerns about medication, especially antidepressants, the nurse should encourage open communication with the healthcare provider. The provider can assess the situation, address side effects, consider adjusting the dosage, or explore alternative medications if needed.
Choice B reason: Reminding the client of the therapeutic effects is helpful for understanding the benefits of the medication, but it does not provide guidance on how to safely discontinue it.
Choice C reason:Tapering is essential for discontinuation, but it should be done under medical supervision. The nurse should first encourage the client to speak with their provider rather than assuming immediate discontinuation.
Choice D reason: While side effects may dissipate over time, this does not provide a solution for the client who wishes to stop the medication now. It is also not guaranteed that all side effects will diminish.
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