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 A
Explanation
A. Continuing antiepileptic drugs is crucial in patients with brain tumors, as these medications help prevent seizure activity, which is a common complication associated with brain tumors and surgical procedures.
B. While pain control is important, the specific medications used for postoperative pain management are determined after surgery; patients should be informed about general pain management strategies rather than specific drug administration.
C. Aspirin, an anticoagulant, should typically be stopped before surgery to reduce the risk of bleeding complications; therefore, patients should not continue taking it unless specifically directed by their healthcare provider.
D. Patients are usually advised to discontinue alternative or complementary therapies before surgery due to potential interactions with anesthesia or surgical procedures, and it should be clarified with the healthcare provider before proceeding.
Correct Answer is C
Explanation
A. Using sunscreen while playing sports is an important measure to protect the skin from harmful UV radiation, which contributes to skin cancer; therefore, this statement indicates proper understanding.
B. Monthly self-examinations for suspicious lesions are recommended as part of early detection strategies for skin cancer, demonstrating a proactive approach to skin health.
C. Decreasing the use of a tanning bed to twice a month still poses a significant risk for skin damage and cancer, as tanning beds expose the skin to high levels of UV radiation. This statement indicates a lack of understanding of the dangers associated with artificial tanning.
D. Wearing a hat and sunglasses while in the sun is an effective strategy for minimizing sun exposure to sensitive areas, protecting the skin and eyes from UV rays, indicating proper sun safety practices.