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. Chewing food on the unaffected side helps to prevent triggering pain episodes in the affected side of the face, which is critical for managing trigeminal neuralgia effectively.
B. While maintaining oral hygiene is important, the timing of brushing teeth is less critical than managing pain during eating. Brushing teeth should be done gently to avoid pain but is not specifically prioritized over other interventions.
C. Avoiding an electric razor is not relevant to managing trigeminal neuralgia pain; it relates more to safety and comfort in shaving rather than pain management.
D. Food should not be served hot or cold as extreme temperatures can trigger pain in trigeminal neuralgia patients; it's better to serve food at a moderate temperature.
Correct Answer is C
Explanation
A. While using the correct needle size is important for insulin administration, it is not the most critical aspect of discharge planning. The focus should be on managing blood glucose levels and recognizing when medical intervention is needed.
B. Monitoring the skin for dryness at the injection site is a good practice, but it is not the most urgent issue to address in discharge planning for a newly diagnosed diabetic client.
C. Consistently elevated blood glucose levels above 200 mg/dL may indicate poor control of diabetes and require prompt adjustments in treatment. Teaching the client to recognize and report hyperglycemia is essential to prevent complications such as diabetic ketoacidosis (DKA).
D. Eye exams are important for long-term diabetes management to monitor for diabetic retinopathy, but every 3 months is excessive. Annual eye exams are typically sufficient unless otherwise indicated by the healthcare provider.