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. Bowel sounds, abdominal girth, and NG tube output provide important information about gastrointestinal function and the potential for complications like ileus or obstruction. However, they do not provide direct information regarding fluid volume status.
B. Vital signs (including blood pressure and heart rate), cardiac rhythm, and peripheral pulses are the first indicators to assess for decreased fluid volume. Hypovolemia often manifests as tachycardia, hypotension, and weak peripheral pulses, which are critical early signs of fluid depletion.
C. Blood Urea Nitrogen (BUN), creatinine, and daily weight are useful in assessing kidney function and long-term fluid status, but they may not be as immediate indicators of acute fluid volume changes in the immediate postoperative period.
D. Respiratory rate, depth, and pulse oximetry are important for assessing respiratory function and oxygenation. While fluid volume imbalances can impact respiratory function, these parameters are not the most direct indicators of fluid volume status.
Correct Answer is A
Explanation
A. Reaction time is slower in older adults due to changes in the central nervous system and decreased neuronal processing speed, which can impact their overall response to stimuli.
B. Pain sensation is not typically heightened in older adults; rather, they may experience a decreased sensitivity to pain due to changes in the nervous system.
C. Higher basal body temperature is generally not associated with aging; older adults often have a lower baseline temperature.
D. While confusion can occur in older adults, it is not considered a normal age-related change and should be further evaluated for underlying causes rather than being expected.