A nurse is assisting in the care of the client who is postoperative following a fasciotomy.
Which of the following actions should the nurse take? Select all that apply.
Prepare to obtain a wound culture.
Restrict fluid intake.
Administer an analgesic
Prepare to administer an antibiotic
Initiate supplemental oxygen.
Correct Answer : A,C,D
A. Prepare to obtain a wound culture: A culture is necessary if infection is suspected.
B. Restrict fluid intake: Contraindicated as hydration is important to support healing and kidney function.
C. Administer an analgesic: Pain management is crucial postoperatively.
D. Prepare to administer an antibiotic: Antibiotics are indicated for infection prophylaxis or treatment.
E. Initiate supplemental oxygen: Not needed unless signs of respiratory distress or hypoxia are present.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Initiate fall precautions: Fall precautions are essential for clients with aspiration pneumonia and hypoxia as they may be disoriented or have impaired oxygenation, increasing the risk of falls.
B. Applying petroleum jelly to the client's nares is not appropriate in this case, as it does not address the client's aspiration pneumonia or hypoxia.
C. Implementing contact precautions is not necessary for aspiration pneumonia unless there is a specific infection that requires isolation precautions (e.g., bacterial infections).
D. Maintaining the client in a supine position can worsen hypoxia and aspiration, as it can facilitate fluid or food moving into the lungs. The client should be maintained in an upright position to promote better oxygenation and prevent aspiration.
Correct Answer is B
Explanation
A. "I can season food with ketchup.": Ketchup is high in sodium and not suitable.
B. "I can season food with vinegar.": Vinegar is low in sodium and appropriate for clients managing hypertension.
C. "I can have a bologna sandwich.": Processed meats like bologna are high in sodium and should be avoided.
D. "I can have canned soup.": Canned soups often contain excessive sodium, making them inappropriate.
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