Urinary tract infections are the most common healthcare-associated infection.

Choice A reason:

Checking the patient’s temperature daily is crucial for early detection of infections. Fever is often one of the first signs of an infection, including Healthcare-Associated Infections (HAIs). Regular monitoring of temperature can help identify infections early, allowing for prompt intervention and treatment. This is particularly important for Mr. Johnson, who is at increased risk due to his recent surgery and the presence of a Foley catheter. Normal body temperature ranges from 97°F to 99°F (36.1°C to 37.2°C).

Choice B reason:

Keeping the surgical dressing in place for the first three post-op days is important for protecting the surgical site from contamination and infection. However, it is not necessarily a strategy to decrease the risk of HAIs beyond the initial postoperative period. The dressing should be changed according to the healthcare provider’s instructions to ensure the wound remains clean and dry. While this is a good practice, it is not as directly related to preventing HAIs as the other interventions.

Choice C reason:

Encouraging and assisting with early ambulation is vital for preventing postoperative complications, including HAIs. Early ambulation helps improve circulation, lung function, and gastrointestinal motility, reducing the risk of complications such as pneumonia and deep vein thrombosis (DVT). It also promotes overall recovery and reduces the length of hospital stay, which in turn decreases the risk of HAIs. Mobilizing patients early can help prevent respiratory infections and other complications associated with prolonged bed rest.

Choice D reason:

Assessing the need for the Foley catheter every shift is essential for preventing catheter-associated urinary tract infections (CAUTIs). Foley catheters are a common source of HAIs, and their use should be minimized whenever possible. Regular assessment of the necessity of the catheter can help ensure it is removed as soon as it is no longer needed, reducing the risk of infection. The CDC recommends removing catheters as soon as they are no longer necessary to prevent CAUTIs.

Choice E reason:

Teaching and encouraging the use of an incentive spirometer is an effective strategy for preventing postoperative respiratory complications, including pneumonia. Incentive spirometry encourages deep breathing and lung expansion, which helps prevent atelectasis and improves oxygenation. This is particularly important for postoperative patients who are at risk of developing respiratory infections due to immobility and the effects of anesthesia. Proper use of an incentive spirometer can significantly reduce the risk of respiratory HAIs.

Choice F reason:

Monitoring laboratory values is important for overall patient care but is not specifically targeted at preventing HAIs. Laboratory values can provide valuable information about the patient’s health status and help guide treatment decisions. However, they do not directly address the prevention of infections. While monitoring lab values is a good practice, it is not as directly related to HAI prevention as the other interventions listed.

Choice A reason:

Potassium (K+) level of 5.6 mEq/L is a critical finding that requires immediate follow-up. Hyperkalemia, defined as a potassium level greater than 5.0 mEq/L, can lead to severe cardiac complications, including arrhythmias and cardiac arrest. The patient’s ECG changes, such as alterations in the T wave and PR interval, indicate that the elevated potassium level is already affecting cardiac function. Immediate intervention is necessary to lower the potassium level and prevent life-threatening complications. Normal potassium levels range from 3.5 to 5.0 mEq/L.

Choice B reason:

BP 109/70 is slightly lower than the normal range but not critically low. While it is important to monitor blood pressure, this finding does not require immediate follow-up compared to the other more critical issues. The patient’s blood pressure should be monitored regularly to ensure it does not drop further, but it is not the most urgent concern at this moment. Normal blood pressure is typically around 120/80 mmHg.

Choice C reason:

No nausea and vomiting is a positive finding indicating that the patient is not losing additional fluids and electrolytes through emesis. While it is important to note, it does not require follow-up as it does not pose an immediate risk to the patient’s health. The absence of nausea and vomiting is beneficial but does not address the primary concerns related to fluid and electrolyte imbalances.

Choice D reason:

Watery diarrhea for 3 days is a significant finding that requires follow-up due to the risk of dehydration and electrolyte imbalances. Diarrhea leads to the loss of fluids and essential electrolytes, which can result in complications such as hypovolemia and electrolyte disturbances. The patient’s ongoing diarrhea needs to be managed to prevent further fluid loss and stabilize their condition. This symptom is directly contributing to the patient’s current state of weakness and electrolyte imbalance.

Choice E reason:

Lightheaded when standing up suggests orthostatic hypotension, which can be a result of dehydration or electrolyte imbalances. This symptom indicates that the patient is experiencing hemodynamic instability, likely due to fluid loss from diarrhea. It is important to address this issue to prevent falls and further complications. Managing the underlying cause, such as rehydration and correcting electrolyte imbalances, will help stabilize the patient’s condition.

Choice F reason:

Blood Urea Nitrogen (BUN) level of 30 mg/dL is elevated, indicating impaired kidney function or dehydration. Normal BUN levels range from 6 to 24 mg/dL. An elevated BUN level suggests that the kidneys are struggling to manage the body’s waste products and fluid balance. This finding is critical for understanding the extent of the patient’s fluid and electrolyte imbalances and guiding appropriate interventions. Addressing the elevated BUN is essential for improving renal function and overall patient health.

Choice G reason:

HR 102 is slightly elevated, indicating tachycardia. Normal heart rate ranges from 60 to 100 beats per minute. Tachycardia can be a sign of dehydration, pain, anxiety, or other underlying conditions. In this case, the elevated heart rate is likely related to the patient’s dehydration and electrolyte imbalances. Monitoring and managing the heart rate is important to ensure the patient’s cardiovascular stability. Interventions to correct fluid and electrolyte imbalances will help normalize the heart rate.

Choice H reason:

Lung sounds are clear is an important assessment finding but does not require follow-up in the context of fluid and electrolyte imbalances. Clear lung sounds indicate that the patient is not experiencing respiratory complications such as pulmonary edema or infection. While this is a positive finding, it does not address the immediate concerns related to the patient’s fluid and electrolyte status.