A nurse is assisting with the care of a client.
Encourage the client to splint the abdomen when coughing.
Administer acetaminophen.
Administer ondansetron.
Remind the client to use the incentive spirometer five times per hr.
Encourage the client to cough and deep breathe.
Plan to ambulate the client 30 min after the next analgesic is administered.
Correct Answer : A,D,E,F
A. Splinting the abdomen helps reduce pain during coughing, making it easier for the client to take deep breaths and effectively clear secretions. This is particularly important after abdominal surgery to minimize discomfort and promote effective coughing.
B. While acetaminophen can help with pain relief, it does not directly address the respiratory status of the client. Therefore, it is not a priority action in this context.
C. Ondansetron is effective for managing nausea, but it does not contribute to improving respiratory status directly. It is necessary for comfort, but it is not an action that promotes respiratory function.
D. The incentive spirometer is a valuable tool for encouraging deep breathing, which helps expand the lungs, improve ventilation, and prevent atelectasis (lung collapse). Regular use of the spirometer is crucial, especially in postoperative clients with decreased mobility.
E. Coughing and deep breathing are essential practices to prevent respiratory complications. They help clear secretions and promote lung expansion, which can improve oxygenation and respiratory function.
F. Ambulation is important for improving respiratory status by promoting lung expansion and circulation. It also aids in preventing complications such as deep vein thrombosis (DVT) and pneumonia. Planning ambulation after administering analgesics ensures that the client is more comfortable and able to participate in this activity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Urinating after specimen collection can contaminate the stool sample; the client should be instructed to collect the stool first.
B. Stool specimens should be kept cool (usually in a refrigerator) to prevent decomposition, not in a warm area.
C. Avoiding placing toilet tissue in the bedpan after defecation is crucial to prevent contamination of the stool specimen, indicating understanding of proper collection techniques.
D. The typical recommendation for stool specimen collection is usually larger than 1.3 cm (0.5 in) and varies based on the type of test; clarity on this guideline is important.
Correct Answer is C
Explanation
A. While a witness may be required, it does not have to be a family member and may vary by state law.
B. Advance directives specify health care preferences, not organ donation, which usually requires a separate directive.
C. Naming a family member, like a sibling, as a designee in a durable power of attorney for health care is appropriate and is part of ensuring that health care decisions align with the client’s wishes if they become unable to communicate.
D. Advance directives do not require an attorney’s approval to be valid; they are enforced based on the client’s wishes as documented.
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