An older client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, which nursing interventions should the nurse include in the client's plan of care? Select all that apply.

Teach client to use incentive spirometer every 2 hours while awake.

Assess pain level and medicate PRN as prescribed.

Maintain sequential compression devices while in bed.

Remove urinary catheter as soon as possible and encourage voiding.

Administer low molecular weight heparin as prescribed.

Answer and Explanation

Correct Answer : A,D

Rationale:

A. Teach client to use incentive spirometer every 2 hours while awake: Using the incentive spirometer promotes lung expansion and helps prevent postoperative pulmonary infections like pneumonia, which are common in older adults after surgery.

B. Assess pain level and medicate PRN as prescribed: Pain management is essential for recovery but does not directly reduce infection risk. While adequate pain control may support deep breathing and mobility, it is not itself an infection-prevention intervention.

C. Maintain sequential compression devices while in bed: Sequential compression devices help prevent deep vein thrombosis but do not directly reduce the risk of infection. They serve a circulatory, not an antimicrobial, purpose.

D. Remove urinary catheter as soon as possible and encourage voiding: Early catheter removal minimizes the risk of catheter-associated urinary tract infections (CAUTIs), which are a major source of healthcare-associated infections in postoperative patients.

E. Administer low molecular weight heparin as prescribed: This medication is used to prevent blood clots, not infection. While important in postoperative care, it does not address infection control directly.

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Correct Answer is A

Explanation

Rationale:
A. Muscle pain: Muscle pain can signal myopathy or rhabdomyolysis, a serious adverse effect of statins that may lead to kidney damage due to muscle breakdown. This symptom requires immediate evaluation to prevent potentially life-threatening complications.

B. Diarrhea and flatulence: These are common gastrointestinal side effects of lovastatin and are usually mild and self-limiting. They do not require urgent intervention unless severe or persistent.

C. Abdominal cramps: Mild abdominal cramping can occur with statin use, often due to GI irritation. While uncomfortable, it is not usually urgent unless accompanied by other severe symptoms like jaundice or persistent nausea.

D. Altered taste: Changes in taste perception may occur with some medications, including statins, but are not typically dangerous. This symptom can affect quality of life but does not indicate an immediate threat.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

Rationale for Correct Choices:

Hyponatremia: The client shows signs of neurological impairment (confusion and altered LOC), which are common symptoms of hyponatremia. The significant, concentrated urine output despite normal IV fluid intake suggests water retention and sodium dilution.
Syndrome of inappropriate antidiuretic hormone (SIADH): A hypothalamic tumor can disrupt normal ADH regulation, leading to SIADH. In SIADH, excessive ADH causes water retention without sodium retention, resulting in dilutional hyponatremia. The high urine output relative to intake further supports inappropriate ADH secretion.

Rationale for Incorrect Choices:

Hypernatremia: This condition is associated with dehydration, increased serum osmolality, and symptoms like thirst and dry mucous membranes, not confusion with preserved fluid intake and high urine output seen here.
Hypokalemia: This typically presents with muscle weakness, cramping, or arrhythmias. It does not account for the client’s confusion or link directly to hypothalamic tumors and fluid imbalance.
Diabetes insipidus: Although linked to hypothalamic or pituitary damage, diabetes insipidus causes hypernatremia due to water loss and low urine osmolality, not confusion from fluid retention and hyponatremia.
Addison’s disease: Addison’s typically presents with hypotension, hyperkalemia, and fatigue. It is an adrenal insufficiency condition, not primarily linked to hypothalamic tumors or SIADH-like fluid handling.

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An older client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, which nursing interventions should the nurse include in the client's plan of care? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse?

Correct Answer is A

Explanation

Patient Data Exhibits Choose the most likely options for the information missing from the statement by selecting from the lists of options provided. The client is showing signs of dropdown related to dropdown.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

A client with chronic kidney disease (CKD) has an arteriovenous (AV) fistula in the left forearm. Which observation by the nurse indicates that the fistula is patent?

Exhibits The primary nurse reviews the client's history and vital signs. Select the 3 priority assessment findings that require immediate follow up.

An older client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, which nursing interventions should the nurse include in the client's plan of care? Select all that apply.