The nurse is caring for a 67-year old client, who is on bedrest. Which of the following nursing actions should the nurse include in the plan of care to help maintain the body's first line of defense? Select all that apply.

Encourage the client to cough and deep breathe.

Turn client every 2 hours.

Keep skin clean and dry.

Apply lotion to clean skin.

Help the client void.

Answer and Explanation

Correct Answer : A,B,C,D,E

A.   Encouraging the client to cough and deep breathe helps to maintain clear airways and prevent respiratory infections.
B.   Turning the client every 2 hours is important for preventing pressure ulcers and maintaining skin integrity.
C.   Keeping the skin clean and dry helps to prevent skin breakdown and infections, serving as a barrier against pathogens.
D.   Applying lotion to clean skin may keep the skin moisturized hence preventing skin breakdown.

E.   Urinary incontinence is associated with skin breakdown hence the development of bedsores. Therefore, assisting the client with voiding is important for maintaining urinary function and skin integrity.

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Correct Answer is B

Explanation

A. Staphylococcus aureus is often susceptible to antibiotics, so supportive interventions without antibiotics would not be appropriate.

B. The most appropriate action for treating an infection caused by Staphylococcus aureus would be to administer an antibiotic to which the organism is sensitive.
C. While wound irrigation may be part of the treatment plan for wound infections, using a hypotonic solution to wash out elevated electrolytes is not specifically indicated for Staphylococcus aureus infections.
D. Applying cold to the wound site would not be the primary treatment for a wound infection caused by Staphylococcus aureus. Antibiotic therapy is necessary to address the bacterial infection.

A. clinical illness phase B. incubation period C. prodromal period D. convalescent period

Correct Answer is B

Explanation

A. The clinical illness phase refers to the stage when signs and symptoms of the disease are present and identifiable.
B. The incubation period is the time between exposure to a pathogen and the onset of symptoms or signs of illness. In this case, the nurse is awaiting the potential development of infection after exposure to the hepatitis B virus.
C. The prodromal period is the time when initial symptoms begin to appear but are not yet specific or fully developed.
D. The convalescent period occurs after the acute phase of illness when the patient is recovering, which does not apply to the nurse's situation immediately after needlestick exposure.

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The nurse is caring for a 67-year old client, who is on bedrest. Which of the following nursing actions should the nurse include in the plan of care to help maintain the body's first line of defense? Select all that apply.

Nursing Test Bank

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