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
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 B
Explanation
A. Washing the skin with water is generally acceptable, but applying scented lotion is not recommended as it may irritate the skin or interfere with treatment; only specific products as advised by the healthcare provider should be used.
B. Skin treatment markings are important for ensuring correct targeting of radiation during therapy and should remain intact for the duration of treatment to avoid misalignment.
C. While some precautions may be necessary, limiting time with others at home is not typically a requirement for external radiation, as it does not make the client radioactive.
D. Skin damage can occur from radiation treatment, and any changes should be reported to the healthcare provider, as monitoring and managing side effects is important for the patient's overall care.
Correct Answer is B
Explanation
A. Requesting antidepressant medication may be appropriate later, but it does not address the immediate need for emotional support and communication.
B. Encouraging the client to verbalize feelings about their diagnosis provides an opportunity for the client to express their concerns and emotions, fostering a therapeutic relationship and aiding in emotional processing.
C. While explaining improved prognosis can provide hope, it may minimize the client’s feelings of fear and uncertainty and could be perceived as dismissive.
D. Allowing time for reflection is important, but it should be balanced with the need for communication and support to prevent isolation.