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

Explanation

A. Promoting full diaphragmatic excursion by massaging the back helps to facilitate deep breathing and lung expansion, which is essential for preventing respiratory complications such as atelectasis and pneumonia after surgery.
B. Noting areas of atelectasis on daily chest x-rays is important for assessing respiratory status, but it is a monitoring intervention rather than a preventive intervention.
C. Assisting the client to a chair the day after surgery when the condition is stable promotes early mobility and prevents complications such as deep vein thrombosis, but it may not directly
address respiratory complications.
D. Providing ice or oral liquids when the client passes flatus may be part of the postoperative care plan, but it does not directly address respiratory complications. It's more related to bowel function and hydration status.

A. Observe color of urine. B. Assess skin turgor. C. Measure body temperature. D. Check for pedal edema.

Correct Answer is A

Explanation

A. Observing the color of urine is crucial when monitoring for adverse effects of prasugrel, as one of the potential adverse effects is bleeding. Hematuria (blood in the urine) can indicate
bleeding complications, which require immediate attention.
B. Assessing skin turgor is not directly related to monitoring for adverse effects of prasugrel.
Skin turgor assessment is typically used to assess hydration status.
C. Measuring body temperature is important for monitoring for signs of infection or inflammation but is not directly related to monitoring for adverse effects of prasugrel.
D. Checking for pedal edema is not directly related to monitoring for adverse effects of
prasugrel. Pedal edema may indicate issues such as fluid overload or venous insufficiency.

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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 nurse is caring for an older adult client who is admitted to the surgical unit following a partial gastrectomy. In addition to frequent position changes, which postoperative intervention is most beneficial for the nurse to perform in preventing respiratory complications?

Correct Answer is A

Explanation

Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this client's plan of care?

Correct Answer is A

Explanation

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