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 C

Explanation

- A) Magnesium level: While magnesium levels can affect cardiac and neuromuscular function, they are not the most critical assessment before potassium infusion. Hypomagnesemia may accompany hypokalemia, but the priority is ensuring renal function to avoid hyperkalemia.
- B) Size of the IV catheter: The size of the IV catheter is important for determining the flow rate of the infusion, but it is not the most critical assessment. The catheter size does not directly impact the safety of potassium administration.
- C)

Potassium chloride administration can cause hyperkalemia if the kidneys are not excreting potassium effectively. Ensuring adequate urinary output before infusion indicates the kidneys are functioning sufficiently to handle the potassium load, making this the most critical assessment.

- D) Serum glucose level:

Although glucose levels are monitored closely in DKA, they are not the primary concern before administering potassium chloride. The priority here is ensuring the kidneys can excrete potassium effectively, as hyperkalemia can be life-threatening.

A. Measure the child's height and weight B. Document lying, sitting, and standing blood pressures C. Locate and mark the pedal pulses D. Perform a mini mental exam on the child E. Obtain a history of allergic reactions F. Determine when the child last ate

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

Explanation

A. Measuring the child's height and weight is essential to ensure appropriate dosing of medications and to assess the child's growth and development.
B. Documenting lying, sitting, and standing blood pressures can help detect orthostatic hypotension, which may be a concern during or after the procedure.
C. Locating and marking the pedal pulses is important for assessing the vascular status of the lower extremities, especially since the catheterization involves accessing a blood vessel.
D. Performing a mini mental exam on the child is not typically part of the pre-cardiac catheterization assessment for a 3-year-old.
E. Obtaining a history of allergic reactions is crucial to prevent any potential allergic response to medications or materials used during the catheterization.
F. Determining when the child last ate is necessary because the child will need to fast for a certain period before the procedure to reduce the risk of aspiration.

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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.

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Naxlex Comprehensive Predictor Exams

A client with type 1 diabetes mellitus (DM) is admitted in diabetic ketoacidosis. Treatment is initiated, and the nurse is preparing to administer IV fluids containing potassium chloride. Which assessment data is most important for the nurse to obtain before starting the infusion?

Correct Answer is C

Explanation

Exhibits Based on the results of the echocardiogram, the physician has decided to repair the ventricular septal via cardiac catheterization. What should the nurse's focused assessment include before the cardiac catheterization? Select all that apply.

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

Explanation

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