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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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

Rationale:

Place client on 2 L/minute oxygen: The client's oxygen saturation is borderline at 94%, and with suspected aortic aneurysm and possible compromise, low-flow oxygen can help ensure adequate tissue oxygenation. This intervention is safe and aligns with the standing PRN order.
Start 0.9% sodium chloride fluid bolus: Given the client’s low-normal blood pressure and risk for aneurysm rupture, fluid resuscitation may be needed to support perfusion. Carefully titrated fluids are appropriate to maintain hemodynamic stability while awaiting definitive surgical management.
Ensure surgical consent has been completed: Time is critical in suspected abdominal aortic aneurysm (AAA) rupture. Preoperative preparation, including confirming surgical consent, should be done early in anticipation of emergent vascular intervention.
Insert indwelling urinary catheter: This is contraindicated until the aneurysm is surgically managed or ruled out. Inserting a catheter increases intra-abdominal pressure and may worsen an unstable aneurysm. Additionally, unnecessary movement may elevate the risk of rupture in a fragile vessel.
Document any skin lesions on lower legs: Peripheral vascular disease is often comorbid with aneurysms. Noting skin lesions helps establish a vascular baseline and may inform intraoperative risk or postoperative wound healing considerations.
Mark pedal pulse sites with a single use marker: Pulse marking is essential preoperatively in vascular cases to monitor distal perfusion post-surgery. Marking now ensures pulses can be quickly located after potential surgical repair of the aneurysm.

A. Consider having the teen's caregiver wait in the clinic reception area. B. Encourage the adolescent to handle the physical exam instruments. C. Allow time for talking before beginning the physical assessment. D. Familiarize the adolescent with the clinic setting and healthcare staff. E. Make every effort to establish eye contact with the adolescent.

Correct Answer is ["B","C","D"]

Explanation

Rationale:
A. Consider having the teen's caregiver wait in the clinic reception area: Adolescents with ASD may experience heightened anxiety in unfamiliar environments. Having their caregiver nearby can offer a sense of security and comfort, making the experience less overwhelming.

B. Encourage the adolescent to handle the physical exam instruments: Allowing the adolescent to touch and explore the equipment before use helps reduce sensory-related anxiety. It also increases cooperation by promoting a sense of predictability and control.

C. Allow time for talking before beginning the physical assessment: Taking time to communicate and build rapport before initiating the assessment helps reduce anxiety and fosters trust. Many adolescents with ASD need more time to process information and adjust to new interactions.

D. Familiarize the adolescent with the clinic setting and healthcare staff: Gradual exposure to the physical space and people helps reduce sensory overload and builds comfort with the environment. Structured familiarity can prevent overstimulation and improve cooperation.

E. Make every effort to establish eye contact with the adolescent: Insisting on eye contact can increase distress, as many individuals with ASD find direct eye contact uncomfortable or overwhelming. Respecting their communication style is more effective than imposing neurotypical expectations.

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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

Exhibits Nurse reviews updated chart data. For each intervention, click to indicate if it is indicated or contraindicated. Each row must have only one response option selected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

An adolescent with autism spectrum disorder (ASD) comes to the clinic for the first time. Which intervention(s) should the nurse implement? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

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