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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)

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

Question Solution

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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A. limit episodes of anticipatory and delayed emesis B. lessen the client's risk of developing neutropenia C. decrease time intervals between remission D. broaden range of cell kill while minimizing toxicities to the client

Correct Answer is D

Explanation

A. While limiting emesis is important in cancer treatment, combination chemotherapy primarily focuses on improving efficacy and minimizing toxicities, not specifically targeting nausea and vomiting episodes.

B. Combination chemotherapy can actually increase the risk of neutropenia due to the cumulative effects of multiple agents, as each may independently lower white blood cell counts.

C. Decreasing time intervals between remission is not a primary goal of combination chemotherapy; rather, it aims to achieve better overall treatment outcomes.

D. The main rationale for using combination chemotherapy is to broaden the range of cancer cell kill through different mechanisms of action while minimizing the side effects associated with higher doses of a single agent. This approach can improve treatment efficacy and reduce the likelihood of resistance.

A. no bowel sounds noted during the assessment. B. an SPO2 which registers 90% while the client is asleep. C. increasing abdominal distention. D. a small amount of green-tinged fluid from the nasogastric tube.

Correct Answer is C

Explanation

A. The absence of bowel sounds shortly after surgery is not uncommon, especially within the first few hours, and does not necessarily indicate a complication at this time.

B. An SPO2 of 90% while the client is asleep may warrant attention, but it is not as critical as signs of a potential surgical complication. The nurse should assess the patient's respiratory status and consider interventions, but immediate notification to the surgeon is not required.

C. Increasing abdominal distention is a concerning sign that may indicate complications such as an anastomotic leak or bowel obstruction, which requires immediate evaluation and possible intervention by the surgeon.

D. A small amount of green-tinged fluid from the nasogastric tube is generally expected postoperatively and does not necessarily indicate a problem, thus does not require immediate notification of the surgeon.

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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)

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Correct Answer is D

Explanation

Correct Answer is C

Explanation

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Take full exam for free 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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The nurse knows the rationale for combination chemotherapy is to:

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:

Correct Answer is C

Explanation

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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)