An older adult client is admitted for the repair of a broken hip. To reduce the risk of infection in the postoperative period, which nursing care interventions should the nurse include in the client's plan of care? Select all that apply.
Teach the client to use an incentive spirometer every 2 hours while awake.
Administer low molecular weight heparin as prescribed.
Assess the pain level and medicate as needed, as prescribed.
Maintain sequential compression devices while in bed.
Remove the urinary catheter as soon as possible and encourage voiding.
Correct Answer : A,E
The correct answer is: A. Teach the client to use an incentive spirometer every 2 hours while awake and E. Remove the urinary catheter as soon as possible and encourage voiding.
Choice A reason:
Teaching the client to use an incentive spirometer every 2 hours while awake helps prevent postoperative pulmonary complications such as pneumonia. This intervention promotes lung expansion and clears secretions, reducing the risk of infection.
Choice B reason:
Administering low molecular weight heparin as prescribed is important for preventing deep vein thrombosis (DVT) and pulmonary embolism, but it does not directly reduce the risk of infection.
Choice C reason:
Assessing the pain level and medicating as needed is crucial for patient comfort and mobility, but it does not directly address infection prevention. Effective pain management can indirectly support recovery by enabling better mobility and respiratory function.
Choice D reason:
Maintaining sequential compression devices while in bed is aimed at preventing DVT, not infections. These devices help improve blood circulation and reduce the risk of blood clots.
Choice E reason:
Removing the urinary catheter as soon as possible and encouraging voiding reduces the risk of catheter-associated urinary tract infections (CAUTIs). Prompt removal of the catheter minimizes the duration of exposure to potential pathogens, thereby reducing infection risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: While developing new screening protocols is a positive step, it does not directly measure the effectiveness of the prevention program in terms of client outcomes or behavior change.
Choice B reason: Early diagnosis of at-risk clients is important, but it is a secondary measure of effectiveness that follows education and behavior change, which are primary prevention strategies.
Choice C reason: Prompt rehabilitation for clients with disease complications is a form of tertiary prevention and does not reflect the effectiveness of the primary prevention program.
Choice D reason: Improvement in client knowledge about specific risk factors as evidenced by test scores is a direct measure of the effectiveness of an educational prevention program. It indicates that clients have understood and potentially internalized the information necessary to prevent sexually transmitted diseases, which is the goal of primary prevention.
Correct Answer is B
Explanation
Choice A reason: Reducing the risk for infection is important but not the primary goal for DJD as it is not primarily an infectious condition.
Choice B reason: Achieving satisfactory pain control is the primary goal in the management of DJD to improve the client's quality of life and functional ability.
Choice C reason: Obtaining adequate rest and sleep is beneficial for overall health but is secondary to pain control in the management of DJD.
Choice D reason: Improving stress management skills can help with overall well-being but is not the primary focus of care for a client with DJD.
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