Review the electronic health record. For each potential nursing intervention, click to specify whether the intervention is indicated or contraindicated

Provide a high-fiber diet rich in fruits and vegetables

Reposition the client every 1-2 hours

Apply thromboembolic deterrent (TED) hose

Decrease fluid intake to less than 1500 mL a day

Complete all hygiene care for the client

Encourage the client to cough and deep breathe

Answer and Explanation

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

• Provide a high-fiber diet rich in fruits and vegetables: Post-operative clients, especially older adults, are at risk for constipation due to immobility and opioid pain medications. Offering a high-fiber diet promotes bowel regularity and prevents complications such as fecal impaction. Adequate nutrition also supports healing and energy levels during recovery.

• Reposition the client every 1-2 hours: Frequent repositioning reduces the risk of pressure injuries, particularly in immobile post-operative clients. It also promotes circulation and prevents discomfort. Early mobilization and turning are essential components of post-operative care to maintain skin integrity and prevent complications.

• Apply thromboembolic deterrent (TED) hose: Post-operative patients are at increased risk for venous thromboembolism due to immobility. TED hose improve venous return, reduce pooling of blood in the lower extremities, and prevent deep vein thrombosis. This intervention is a standard preventive measure after orthopedic surgery.

• Decrease fluid intake to less than 1500 mL a day: Restricting fluids in a post-operative client with low oxygen saturation (88% on room air) is contraindicated. Adequate hydration is necessary to maintain blood volume, support kidney function, and prevent complications. Limiting fluid intake could exacerbate hypotension, hypoxia, or dehydration.

• Complete all hygiene care for the client: Assisting with hygiene helps prevent skin breakdown, reduces infection risk, and promotes comfort. Maintaining cleanliness is crucial in post-operative recovery and supports overall health. This intervention is indicated for clients with limited mobility.

• Encourage the client to cough and deep breathe: After surgery, especially following immobility and anesthesia, clients are at risk for atelectasis and pneumonia. Encouraging deep breathing and coughing promotes lung expansion, enhances oxygenation, and clears secretions.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. All visitors should wear hair and shoe covers: Hair and shoe covers are not part of standard contact precautions for MRSA. Transmission occurs primarily through direct contact with contaminated surfaces or wounds rather than hair or footwear. Routine use of these items does not reduce MRSA spread.

B. All visitors should wear a gown and gloves: MRSA requires contact precautions to prevent transmission via hands and clothing. Gowns protect clothing from contamination, and gloves reduce direct contact with infectious material. This practice is consistent with infection prevention guidelines for multidrug-resistant organisms.

C. All visitors should wear goggles and gloves: Eye protection is reserved for situations with a risk of splashing or spraying of body fluids. MRSA wound care does not typically pose this risk during routine contact. Goggles are not routinely indicated.

D. All visitors should wear an N95 mask and gown: N95 respirators are used for airborne pathogens such as tuberculosis, not contact-spread organisms like MRSA. Respiratory protection is unnecessary unless aerosol-generating procedures are involved.

A. "I will encourage him to walk daily so his muscles get stronger." B. "I will ensure he inserts his dentures so he can eat well during the day." C. "I will remind him to shift in his chair at least every two hours." D. "I will change his incontinence brief about every eight hours or so."

Correct Answer is D

Explanation

A. "I will encourage him to walk daily so his muscles get stronger.": Ambulation improves circulation, reduces prolonged pressure on bony prominences, and supports muscle strength needed for repositioning. Regular movement is a key preventive strategy for pressure injury development. Mobility also enhances overall skin integrity.

B. "I will ensure he inserts his dentures so he can eat well during the day.": Adequate nutrition supports tissue repair, immune function, and skin resilience. Proper denture use promotes sufficient caloric and protein intake. Nutrition is a foundational component of pressure injury prevention.

C. "I will remind him to shift in his chair at least every two hours.": Regular repositioning redistributes pressure and restores capillary blood flow to compressed tissues. While chair-bound clients often benefit from more frequent shifts, this practice still reflects appropriate preventive awareness. Pressure relief is essential for skin protection.

D. "I will change his incontinence brief about every eight hours or so.": Prolonged moisture exposure from urine or stool increases skin maceration and susceptibility to breakdown. Incontinence care requires frequent brief changes and prompt skin cleansing. Moisture management is critical in preventing pressure injuries.

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Review the electronic health record. For each potential nursing intervention, click to specify whether the intervention is indicated or contraindicated

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse plans care for a client with a wound positive for methicillin-resistant Staphylococcus aureus (MRSA). What action should the nurse include in the care of this client?

Correct Answer is B

Explanation

The nurse provided discharge teaching to the client's family on preventing pressure injuries at home. Which statement made by the family member indicates a need for further instruction?

Correct Answer is D

Explanation

The nurse cares for a client with a wound. What assessment(s) should the nurse complete during the inspection phase of the wound assessment? Select all that apply.

The nurse is planning to assist a client to transfer from the bed to the chair. Which healthcare provider order should the nurse consider in planning for the client's transfer to the chair?

Which statement(s) uphold the principles of sterility? Select all that apply.

For each asepsis example, click to specify whether it describes medical asepsis or surgical asepsis.

Date/Time: 4/11/XXX 1402 Review the electronic health record. What is the client's risk for falls?

Review the electronic health record. The nurse is preparing the client for discharge. After the nurse provides education about the use of a cane, which statement by the client indicates understanding?

The nurse is planning care for a client after surgery. Which nutrition intervention should the nurse include in the plan of care?

The nurse is preparing to provide wound care for a group of clients in the outpatient setting. The nurse understands which action is considered best practice when providing wound care?