The nurse is planning care that would decrease the risk for infection in a client who is recovering from a colectomy. The nurse would include which intervention(s)? (SELECT ALL THAT APPLY)

Encourage and assist with use of incentive spirometer every hour while awake

Assist client out of bed on post-operative day 1

Reposition client every four hours while in bed

Utilize aseptic technique while changing dressing

Maintain TEDS and SCD's while in bed

Answer and Explanation

Correct Answer : A,D,E

A. Encouraging the use of an incentive spirometer helps prevent respiratory complications and promotes lung expansion, thereby reducing the risk of infection, particularly pneumonia.
B. While early mobilization is important for recovery, assisting the client out of bed on post-operative day 1 may not be appropriate depending on the patient's condition; this option is not directly related to infection prevention.
C. Repositioning every four hours is important for pressure ulcer prevention but does not directly impact infection risk; more frequent repositioning may be necessary to ensure adequate skin integrity and circulation.
D. Utilizing aseptic technique while changing the dressing is crucial for preventing infection at the surgical site, making this a vital intervention.
E. Maintaining TEDS (thromboembolic deterrent stockings) and SCDs (sequential compression devices) helps prevent deep vein thrombosis (DVT) and improves circulation, which can indirectly reduce infection risk by promoting better blood flow.

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Correct Answer is C

Explanation

A. Applying pressure to injection sites helps reduce bleeding but does not directly prevent tumor lysis syndrome.
B. Monitoring telemetry is important for patients with potential cardiac issues but is not specifically related to preventing complications from tumor lysis syndrome.
C. Ensuring a high fluid intake of 3000 to 5000 mL/day helps dilute electrolytes and reduce the risk of acute kidney injury and other complications associated with tumor lysis syndrome, making this the most crucial intervention.
D. Assisting the client in ambulatory activities may support their overall well-being but does not address the prevention of tumor lysis syndrome.

A. Degree of upper body vasculature observed. B. Arm circumference and degree of edema. C. Blood pressure and heart rate. D. Peripheral sensation and movement of upper extremities.

Correct Answer is C

Explanation

A. Assessing the degree of upper body vasculature may provide some information, but it does not directly address the client's current symptoms or vital status.
B. Measuring arm circumference and evaluating the degree of edema are important for understanding the extent of swelling but do not assess the client’s hemodynamic stability or respiratory status.
C. Blood pressure and heart rate are critical assessments in this scenario, especially considering the client’s dyspnea and upper body edema. Changes in these vital signs can indicate potential respiratory distress, compromised cardiac function, or anaphylaxis, which requires immediate intervention.
D. While assessing peripheral sensation and movement is important for overall neurological function, it is not a priority in this context compared to assessing vital signs that can directly affect the client’s stability.

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The nurse is planning care that would decrease the risk for infection in a client who is recovering from a colectomy. The nurse would include which intervention(s)? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which intervention is most important for the nurse to implement to prevent complications from tumor lysis syndrome during chemotherapy?

Correct Answer is C

Explanation

The nurse is admitting a client who reports symptoms of dyspnea. The nurse notes edema of the upper arms, face, and neck. What is the nurse's priority assessment?

Correct Answer is C

Explanation

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