The nurse is caring for a 67-year old client, who is on bedrest. Which of the following nursing actions should the nurse include in the plan of care to help maintain the body's first line of defense? Select all that apply.

Encourage the client to cough and deep breathe.

Turn client every 2 hours.

Keep skin clean and dry.

Apply lotion to clean skin.

Help the client void.

Answer and Explanation

Correct Answer : A,B,C,D,E

A.   Encouraging the client to cough and deep breathe helps to maintain clear airways and prevent respiratory infections.
B.   Turning the client every 2 hours is important for preventing pressure ulcers and maintaining skin integrity.
C.   Keeping the skin clean and dry helps to prevent skin breakdown and infections, serving as a barrier against pathogens.
D.   Applying lotion to clean skin may keep the skin moisturized hence preventing skin breakdown.

E.   Urinary incontinence is associated with skin breakdown hence the development of bedsores. Therefore, assisting the client with voiding is important for maintaining urinary function and skin integrity.

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Correct Answer is D

Explanation

A. Urine culture and sensitivity tests typically take longer than 30 minutes to yield results.
B. While some preliminary results may be available within 24 hours, the full culture and sensitivity testing usually take longer.
C. Waiting 7-10 days for results would be excessive for a urine culture and sensitivity test.
D. Typically, it takes 48-72 hours to obtain the growth and sensitivity results for a urine culture, allowing time for bacterial growth and sensitivity testing.

A. A client age 52 who had gall bladder surgery and has osteoarthritis B. A client age 18 who had plastic surgery on nose and is overweight C. A client age 45 with a fractured wrist and in pain D. A client age 78 with Rheumatoid arthritis who had foot surgery and a Foley catheter inserted

Correct Answer is D

Explanation

A. While gall bladder surgery carries a risk of infection, having osteoarthritis does not significantly increase the risk compared to other factors listed.
B. Plastic surgery and being overweight may increase the risk of surgical site infections, but age and comorbidities are more significant factors.

C. A fractured wrist may increase the risk of infection at the fracture site, but it is not as significant a risk factor as advanced age and comorbidities.
D. Advanced age, rheumatoid arthritis, foot surgery, and Foley catheter insertion are all factors that increase the risk of infection, making this client the most vulnerable.

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The nurse is caring for a 67-year old client, who is on bedrest. Which of the following nursing actions should the nurse include in the plan of care to help maintain the body's first line of defense? Select all that apply.

Nursing Test Bank

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Correct Answer is D

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