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.

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A reason: While the fall is important, it is not the most immediate concern for the healthcare provider in the context of SBAR communication.

Choice B reason: Increasing confusion can indicate a change in the client's condition and may require immediate intervention, making it the priority in SBAR communication.

Choice C reason: The client's healthcare power of attorney is important for legal and consent purposes but is not the first piece of information to provide in an SBAR report.

Choice D reason: Currently prescribed medications are part of the background information and would follow after the immediate situation has been described.

A. Assume care of the client and assign the PN to the care of a different client. B. Arrange for unlicensed assistive personnel to assist the PN during the procedure. C. Acknowledge that the PN has positioned the client safely and correctly. D. Demonstrate to the PN how to position the client more effectively for the procedure.

Correct Answer is D

Explanation

Choice A reason: Assuming care of the client and reassigning the PN does not address the immediate need to correct the client's position for the sigmoidoscopy.

Choice B reason: While assistance may be needed, it is more important to first ensure that the client is in the correct position for the procedure.

Choice C reason: Acknowledging the PN's action would be incorrect since the client has not been positioned safely and correctly for a sigmoidoscopy.

Choice D reason: Demonstrating the correct positioning ensures the procedure can be performed effectively and safely, which is the nurse's immediate responsibility.

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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.

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

Correct Answer is D

Explanation

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