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 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.
Correct Answer is C
Explanation
A. Slowing the rate of infusion may provide some temporary relief, but it does not address the underlying issue and may worsen the situation.
B. Applying a warm compress may soothe discomfort but is not the priority action when a burning sensation is reported, which could indicate potential extravasation.
C. Discontinuing the infusion is the best first action to prevent further damage to the tissue and to assess for complications such as infiltration or extravasation.
D. Checking for blood return can help assess the patency of the IV line, but the priority is to stop the infusion immediately to prevent complications.