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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: While obtaining a 12-lead electrocardiogram is important for monitoring cardiac function, it is not as frequent or specific as potassium monitoring for hyperkalemia management.
Choice B reason: Evaluating glucose levels is necessary due to the risk of hypoglycemia from insulin administration, but the priority is monitoring potassium levels in hyperkalemia.
Choice C reason: Monitoring intake and output is part of fluid balance management but is secondary to the critical need to monitor serum potassium levels.
Choice D reason: Frequent assessment of serum potassium levels is essential to evaluate the effectiveness of the dextrose and insulin therapy in lowering potassium levels.
Correct Answer is C
Explanation
Choice A reason: Hypothermia is not typically associated with hyperparathyroidism and does not require specific precautions in this context.
Choice B reason: Aspiration may be a concern for patients with severe hypercalcemia if they have altered mental status, but it is not the primary safety precaution.
Choice C reason: Falls are a significant risk due to potential muscle weakness, skeletal fragility, and possible neuromuscular symptoms caused by hypercalcemia.
Choice D reason: Suicide is not directly related to hyperparathyroidism; however, mental health should always be monitored in patients with chronic conditions.
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