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. Reading glasses do not offer sufficient protection against the light sensitivity that results from photodynamic therapy. Special protective eyewear is needed to protect the eyes from exposure to bright light during recovery.
B. Clients are usually instructed to fast before treatments that involve anesthesia or sedation, such as photodynamic therapy. Eating a full breakfast is not typically recommended before this type of treatment.
C. After photodynamic therapy, clients become extremely sensitive to light, including sunlight. Exposure to sunlight or strong indoor lights can cause skin damage, so clients are advised to avoid sun exposure for at least 6 weeks.
D. Skin markings made for treatment guidance should be preserved between treatments, but this is less critical in photodynamic therapy compared to radiation therapy, where precise location is essential for targeting tumors.

A. Large cluster of pustules in the right axilla B. Raised, tubular, white areas on the arms C. Beige, small brown spots on the backs of both hands D. Irregular shaped, blue mole with white specks on lower leg

Correct Answer is D

Explanation

A. A large cluster of pustules may indicate an infection or inflammatory process, but it is not necessarily indicative of an immediate danger compared to other options.
B. Raised, tubular, white areas may represent benign conditions, such as skin tags or cysts, which generally do not require urgent evaluation unless symptomatic.
C. Beige, small brown spots are often benign, such as liver spots or freckles; these typically do not signal immediate concern unless there are changes in size or color.
D. An irregular shaped, blue mole with white specks raises significant concern for potential melanoma, a serious form of skin cancer; any atypical characteristics in moles warrant immediate evaluation to rule out malignancy.

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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

In planning teaching sessions for a client undergoing photodynamic therapy for lung cancer, the nurse should include which statement?

Correct Answer is C

Explanation

A client has numerous skin lesions. Which one will the nurse evaluate first?

Correct Answer is D

Explanation

The nurse is caring for a client who had a bowel resection 2 hours ago for adenocarcinoma removal. It would be necessary for the nurse to immediately notify the surgeon if the client's assessment revealed:

The client has been diagnosed with a frontal lobe brain tumor and has undergone a craniotomy. What position should the nurse place the client post-operatively?

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)

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