The nurse encourages the 84-year-old patient who is recovering from a hip replacement to:
Keep the bed flat to aid in lung expansion.
Cough frequently to make up for the loss of cilia.
Encourage bed rest.
Restrict fluid to prevent pulmonary congestion.
The Correct Answer is B
Choice A rationale
Keeping the bed flat does not necessarily aid lung expansion and can sometimes increase the risk of aspiration in patients with compromised mobility or cognition.
Choice B rationale
Encouraging the patient to cough frequently helps clear secretions from the lungs, compensating for the diminished function of cilia in elderly patients.
Choice C rationale
Encouraging bed rest can lead to complications such as muscle atrophy, decreased lung capacity, and increased risk of pressure ulcers in elderly patients.
Choice D rationale
Restricting fluid intake to prevent pulmonary congestion is not generally recommended unless there is a specific medical condition requiring fluid restriction, as adequate hydration is vital for overall health.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Limiting ambulation can increase the risk of complications such as deep vein thrombosis and does not necessarily reduce HAIs.
Choice B rationale
Encouraging the patient to turn, cough, and deep breathe every 2 hours helps prevent respiratory complications, improves lung function, and reduces the risk of pneumonia, a common HAI.
Choice C rationale
Keeping the room door closed does not prevent HAIs and might isolate the patient, reducing mobility and social interaction.
Choice D rationale
Regular monitoring of vital signs is essential but does not directly reduce the risk of HAIs. Other measures, like proper hygiene and mobilization, are more effective.
Correct Answer is D
Explanation
Choice A rationale
Disinfectants are not intended for use on the patient's body. Using them around the eyes or mouth can cause irritation or harm, as they are designed to kill or inhibit the growth of microorganisms on inanimate objects.
Choice B rationale
It is important to thoroughly clean and rinse all soap off equipment before disinfecting, as organic matter and soap residues can interfere with the disinfectant's effectiveness. Proper cleaning removes debris that can protect microorganisms from the disinfectant.
Choice C rationale
Disinfectants cannot sterilize instruments as sterilization refers to the complete elimination of all forms of microbial life, including spores. Bacteriostatic disinfectants only inhibit bacterial growth and do not achieve sterilization.
Choice D rationale
Removing organic matter prior to disinfecting is crucial because organic material can protect microorganisms from the disinfectant, reducing its effectiveness. Proper cleaning ensures that the disinfectant can directly contact and eliminate the microorganisms.
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