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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
A. The reservoir is the source of infectious agents, not the method by which they enter the body.
B. Meticulous sterile technique during wound care procedures helps prevent microorganisms from entering the body, thereby controlling the portal of entry for potential pathogens.
C. Characteristics of the organism refer to factors such as virulence and pathogenicity, which influence the organism's ability to cause infection but are not directly controlled by sterile technique during wound care.
D. The portal of exit is the route by which infectious agents leave the reservoir, such as through respiratory secretions or bodily fluids, and is not directly controlled by sterile technique during wound care.
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