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

Answer and Explanation

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.

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Correct Answer is ["A","B","C"]

Explanation

A. An irregular border is a key characteristic of potentially cancerous skin lesions, particularly melanoma. Melanomas often have uneven, poorly defined edges.
B. Asymmetry is another sign of melanoma. If one half of a lesion does not match the other in shape or size, it should be evaluated by a healthcare professional.
C. Any lesion that has been increasing in size, particularly over a short period, is a concern and should be checked. Rapid growth can be a sign of malignancy.
D. A lesion with a diameter of less than 4 mm is generally less concerning, as most cancerous lesions are larger. However, the other factors (such as asymmetry and border irregularity) are more significant for diagnosis.
E. Ecchymosis (bruising) is not typically associated with cancerous skin lesions. Skin cancers like melanoma present as new or changing moles, not bruising.

A. Request a prescription to culture the wound B. Request a prescription for broad spectrum antibiotics C. Assure the client this is normal in the healing process D. Clean the wound with sterile normal saline

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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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)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is educating adolescent high school students about when to seek medical attention regarding suspected cancerous skin lesions. Which of the following are included in the nurse's teaching? The lesion has:

Correct Answer is ["A","B","C"]

Explanation

The nurse is assessing a client who had a surgical excision of a basal cell carcinoma one week ago. Assessment findings include redness, warmth, and serosanguinous drainage from the site. What would be the priority action by the nurse?

Correct Answer is A

Explanation

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