Exhibits
Select 4 interventions, assessments, and patient education strategies you would use to decrease the risk of a Healthcare-Associated Infection (HAI) for Mr. Johnson.
Check the patient’s temperature daily.
Keep the surgical dressing in place for the first three post-op days.
Encourage and assist with early ambulation.
Assess the need for the Foley catheter every shift.
Teach and encourage the use of an incentive spirometer.
Monitor laboratory values.
Correct Answer : A,C,D,E
Choice A reason:
Checking the patient’s temperature daily is crucial for early detection of infections. Fever is often one of the first signs of an infection, including Healthcare-Associated Infections (HAIs). Regular monitoring of temperature can help identify infections early, allowing for prompt intervention and treatment. This is particularly important for Mr. Johnson, who is at increased risk due to his recent surgery and the presence of a Foley catheter. Normal body temperature ranges from 97°F to 99°F (36.1°C to 37.2°C).
Choice B reason:
Keeping the surgical dressing in place for the first three post-op days is important for protecting the surgical site from contamination and infection. However, it is not necessarily a strategy to decrease the risk of HAIs beyond the initial postoperative period. The dressing should be changed according to the healthcare provider’s instructions to ensure the wound remains clean and dry. While this is a good practice, it is not as directly related to preventing HAIs as the other interventions.
Choice C reason:
Encouraging and assisting with early ambulation is vital for preventing postoperative complications, including HAIs. Early ambulation helps improve circulation, lung function, and gastrointestinal motility, reducing the risk of complications such as pneumonia and deep vein thrombosis (DVT). It also promotes overall recovery and reduces the length of hospital stay, which in turn decreases the risk of HAIs. Mobilizing patients early can help prevent respiratory infections and other complications associated with prolonged bed rest.
Choice D reason:
Assessing the need for the Foley catheter every shift is essential for preventing catheter-associated urinary tract infections (CAUTIs). Foley catheters are a common source of HAIs, and their use should be minimized whenever possible. Regular assessment of the necessity of the catheter can help ensure it is removed as soon as it is no longer needed, reducing the risk of infection. The CDC recommends removing catheters as soon as they are no longer necessary to prevent CAUTIs.
Choice E reason:
Teaching and encouraging the use of an incentive spirometer is an effective strategy for preventing postoperative respiratory complications, including pneumonia. Incentive spirometry encourages deep breathing and lung expansion, which helps prevent atelectasis and improves oxygenation. This is particularly important for postoperative patients who are at risk of developing respiratory infections due to immobility and the effects of anesthesia. Proper use of an incentive spirometer can significantly reduce the risk of respiratory HAIs.
Choice F reason:
Monitoring laboratory values is important for overall patient care but is not specifically targeted at preventing HAIs. Laboratory values can provide valuable information about the patient’s health status and help guide treatment decisions. However, they do not directly address the prevention of infections. While monitoring lab values is a good practice, it is not as directly related to HAI prevention as the other interventions listed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: True
The statement that a patient with alkalosis can develop hyperkalemia is generally incorrect. Alkalosis, which is a condition characterized by a higher-than-normal pH in the blood, typically leads to hypokalemia rather than hyperkalemia. This occurs because alkalosis causes potassium to shift from the extracellular fluid into the cells, reducing the plasma potassium concentration. Therefore, it is uncommon for alkalosis to result in hyperkalemia.
Choice B: False
The correct answer is that a patient with alkalosis is unlikely to develop hyperkalemia. Alkalosis usually causes a decrease in plasma potassium levels, leading to hypokalemia. This is due to the movement of potassium ions into the cells in exchange for hydrogen ions, which are moved out of the cells to help buffer the increased pH. Consequently, the plasma potassium concentration drops, making hyperkalemia an unlikely outcome in the presence of alkalosis.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A reason:
Changing the patient’s position every 3 to 4 hours is crucial to prevent complications such as pressure ulcers and deep vein thrombosis (DVT). Immobility can lead to the development of pressure ulcers, especially in patients who are bedridden or have limited mobility. Regular repositioning helps to alleviate pressure on vulnerable areas of the body, promoting better circulation and preventing skin breakdown. Additionally, changing positions can help in preventing DVT by encouraging blood flow and reducing the risk of blood clots forming in the legs.
Choice B reason:
Providing adequate and regular pain medication is essential for postoperative care to ensure patient comfort and facilitate recovery. Pain management is a critical aspect of postoperative care as unmanaged pain can lead to complications such as increased heart rate, hypertension, and delayed wound healing. Adequate pain control allows the patient to participate in necessary activities such as deep breathing exercises and ambulation, which are vital for preventing complications like pneumonia and promoting overall recovery. Pain medication should be administered as prescribed, and the patient’s pain levels should be regularly assessed and documented.
Choice C reason:
Encouraging deep breathing and coughing is vital for preventing respiratory complications such as atelectasis and pneumonia. After surgery, patients are at risk of developing these complications due to the effects of anesthesia and prolonged immobility. Deep breathing exercises help to expand the lungs fully, improving oxygenation and preventing the collapse of alveoli. Coughing helps to clear secretions from the airways, reducing the risk of infection. Nurses should instruct patients on how to perform these exercises effectively and encourage them to do so regularly.
Choice D reason:
Placing the conscious patient in a supine position with the head of the bed elevated is important for maintaining airway patency and promoting optimal respiratory function. Elevating the head of the bed helps to reduce the risk of aspiration and improves lung expansion, facilitating better breathing. This position is particularly beneficial for patients who may have residual effects of anesthesia or are at risk of respiratory complications. It also helps in reducing the workload on the heart and improving overall comfort.
Choice E reason:
Encouraging bed rest for the first 4 hours after surgery is generally not recommended as early mobilization is crucial for preventing complications such as DVT, pulmonary embolism, and muscle atrophy. While it is important to ensure that the patient is stable before encouraging movement, prolonged bed rest can lead to adverse outcomes. Instead, patients should be encouraged to engage in light activities as soon as they are able, under the supervision of healthcare professionals. This helps to promote circulation, improve respiratory function, and enhance overall recovery.
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