The nurse is planning care that would decrease the risk for infection in a client who is recovering from a colectomy. The nurse would include which intervention(s)? (SELECT ALL THAT APPLY)
Encourage and assist with use of incentive spirometer every hour while awake
Assist client out of bed on post-operative day 1
Reposition client every four hours while in bed
Utilize aseptic technique while changing dressing
Maintain TEDS and SCD's while in bed
Correct Answer : A,D,E
A. Encouraging the use of an incentive spirometer helps prevent respiratory complications and promotes lung expansion, thereby reducing the risk of infection, particularly pneumonia.
B. While early mobilization is important for recovery, assisting the client out of bed on post-operative day 1 may not be appropriate depending on the patient's condition; this option is not directly related to infection prevention.
C. Repositioning every four hours is important for pressure ulcer prevention but does not directly impact infection risk; more frequent repositioning may be necessary to ensure adequate skin integrity and circulation.
D. Utilizing aseptic technique while changing the dressing is crucial for preventing infection at the surgical site, making this a vital intervention.
E. Maintaining TEDS (thromboembolic deterrent stockings) and SCDs (sequential compression devices) helps prevent deep vein thrombosis (DVT) and improves circulation, which can indirectly reduce infection risk by promoting better blood flow.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. An otoscope is used to examine the ear canal and tympanic membrane, not to assess cranial nerve III. This tool is more relevant for assessing cranial nerve VIII (vestibulocochlear), which is responsible for hearing and balance.
B. A penlight is used to assess CN III (oculomotor) by evaluating the pupil's response to light and the ability to move the eye. This nerve controls most of the eye's movements, including constriction of the pupil in response to light.
C. A cotton ball is used to test the sensory function of cranial nerve V (trigeminal), which is responsible for facial sensation. It is not used for assessing CN III.
D. Lavender or other scents may be used to test CN I (olfactory), responsible for the sense of smell, but it is not related to CN III, which governs eye movements and pupil reactions.
Correct Answer is A
Explanation
A. Requesting a prescription to culture the wound is the priority action because the presence of redness, warmth, and serosanguinous drainage could indicate an infection that needs to be confirmed and treated appropriately.
B. While antibiotics may be necessary if an infection is confirmed, it is crucial to first determine the presence of infection through culturing the wound.
C. Assuring the client that these findings are normal may delay necessary intervention if an infection is present, which could worsen the client's condition.
D. Cleaning the wound with sterile normal saline may be appropriate as part of wound care, but it does not address the underlying concern of possible infection and would not be prioritized over obtaining a culture.
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