A nurse is assisting with the care of a client.

Exhibits
Which of the following actions should the nurse take to promote the client's respiratory status? Select all that apply.

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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Turning off bedside alarms is unsafe, as they are crucial for monitoring the client’s condition.

B. Avoiding the client’s room entirely could lead to missed opportunities to assess and address their needs.

C. Conducting staff communications away from the client's room can reduce noise and create a more restful environment.

D. Turning on the TV may add to the noise and is unlikely to promote restful sleep.

A. The stoma bleeds lightly when touched. B. The stoma appears dark in color. C. The stoma protrudes slightly from the abdomen. D. The stoma is draining a small amount of liquid stool.

Correct Answer is B

Explanation

A. Light bleeding from the stoma can be normal in the early postoperative period, but it should be monitored.

B. A dark-colored stoma can indicate ischemia or compromised blood supply, which is a critical finding that requires immediate reporting to the provider.

C. Slight protrusion of the stoma is typically expected and not a cause for concern.

D. Small amounts of liquid stool from the stoma are normal in the immediate postoperative period and do not need to be reported.

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Body system	Findings
Neurological	Alert and oriented to person, place, and time: deep tendon reflexes 4+
Musculoskeletal	Generalized weakness with equal bilateral muscle strength and mild leg cramping
Respiratory	Lungs clear
Cardiovascular	Heart rate irregular: Heart rate 95/min
Gastrointestinal	Bowel sounds hyperactive x 4 quadrants

A nurse is assisting with the care of a client. Exhibits Which of the following actions should the nurse take to promote the client's respiratory status? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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A nurse is assisting with the care of a client.

Exhibits
Which of the following actions should the nurse take to promote the client's respiratory status? Select all that apply.