An older adult client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, what nursing care intervention(s) should the nurse include in the client's plan of care? Select all that apply.

Maintain sequential compression devices while in bed.

Teach client to use incentive spirometer every 2 hours while awake.

Assess pain level and medicate PRN as prescribed.

Remove urinary catheter as soon as possible and encourage voiding.

Administer low molecular weight heparin as prescribed.

Answer and Explanation

Correct Answer : B,D

SCDs are effective for preventing DVT but are not directly related to infection prevention. The focus here is more on preventing respiratory and urinary infections.

B.   Teaching the client to use an incentive spirometer every 2 hours while awake helps prevent
atelectasis and pneumonia by promoting deep breathing and lung expansion, reducing the risk of respiratory infections.
C.   Assessing pain level and medicating PRN as prescribed is important for postoperative comfort but is not directly related to reducing the risk of infection.
D.   Removing the urinary catheter as soon as possible and encouraging voiding helps reduce the risk of urinary tract infections, which are common in clients with prolonged catheter use.
E.   Low molecular weight heparin helps prevent blood clots, reducing the risk of thrombosis, which can increase the risk of postoperative complications, including infections.

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

Explanation

A. Shaking that changes the child's handwriting legibility could indicate a neurological or motor issue and warrants further assessment by the school nurse.
B. Bruises on both knees after the weekend are likely minor and do not typically require immediate referral to the school nurse unless there are other concerning signs of abuse or injury.

C. Sunburn with blisters on the face, arms, and hands could indicate severe sunburn and potential complications such as infection or dehydration, requiring evaluation by the school nurse.
D. Refusing to complete written homework assignments may indicate behavioral issues or difficulties with learning but does not necessarily require immediate referral to the school nurse.

E. Thirst and frequent requests for bathroom breaks could indicate underlying medical issues such as diabetes or urinary tract infection and should be reported to the school nurse for further assessment.

A. Give lactated Ringers IV at 66 mL/hr while NPO B. Vital signs every 4 hours C. Place the child on a continuous cardiopulmonary monitor D. Admit to the pediatric floor for observation E. NPO F. Point of care blood glucose G. Check pedal pulses every 4 hours

Correct Answer is ["A","F"]

Explanation

A. Post-cardiac catheterization patients require careful monitoring of fluid intake to avoid fluid overload, which can stress the heart and lead to complications.
B. Monitoring vital signs every 4 hours is a standard procedure for a patient post-cardiac catheterization to ensure stability.
C. Continuous cardiopulmonary monitoring is also standard post-procedure to promptly detect any arrhythmias or other cardiopulmonary issues.
D. Admission to the pediatric floor for observation is appropriate for monitoring and ensuring the safety of the patient post-procedure.
E. Keeping the patient NPO (nothing by mouth) is standard until they are fully awake and alert post-anesthesia to prevent aspiration.
F. Point of care blood glucose: This order might be questioned as there is no indication from the history or notes that the child has a blood glucose issue. Monitoring blood glucose is not typically a standard post-cardiac catheterization order unless there is a specific concern for blood sugar levels.
G. Checking pedal pulses every 4 hours is important to ensure there is no compromise in circulation, especially after a procedure involving the heart.
H. Checking the dressing frequently is crucial to identify any signs of bleeding or infection early.

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An older adult client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, what nursing care intervention(s) should the nurse include in the client's plan of care? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The school nurse is preparing a presentation for elementary school teachers to inform them about when a child should be referred to the school clinic for further follow-up. The teachers should be instructed to report what situation(s) to the school nurse? Select all that apply.

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

Explanation

Exhibits The nurse reviews the post catheterization orders. Which two orders would the nurse question?

Correct Answer is ["A","F"]

Explanation

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