A nurse is caring for a client.

Exhibits

Which of the following actions should the nurse take? (Select all that apply.)

A. Repositioning in bed: While repositioning the client is important for comfort and preventing complications such as pressure ulcers, it is not the top priority immediately after a pneumonectomy. Proper positioning can help improve respiratory function, but ensuring the stability and function of chest drainage systems takes precedence in the immediate postoperative period.
B. Use of the incentive spirometer: Encouraging the use of an incentive spirometer is crucial for promoting lung expansion and preventing atelectasis. However, it is essential first to ensure that the client’s chest tube is functioning properly and that there are no complications from the surgery. While this intervention is important, it follows the need to assess the chest tube.
C. Application of antiembolism stockings: While applying antiembolism stockings is a good practice to prevent venous thromboembolism, it is not the highest priority in the immediate postoperative period. Other assessments and interventions, such as monitoring respiratory status and chest tube function, are more critical in this early stage after surgery.
D. Chest tube and pleura-vac assessment: This is the priority nursing intervention in the immediate postoperative period. After a pneumonectomy, monitoring the chest tube's placement, drainage output, and function is vital for ensuring that the pleural space is adequately drained and that there are no complications such as pneumothorax or hemothorax. This assessment is crucial for maintaining respiratory function and overall stability in the postoperative client.

• Clostridium difficile infection is likely because the client has pneumonia and is receiving ceftriaxone, an antibiotic known to disrupt gut flora and cause opportunistic infections like C. difficile. The presence of frequent, liquid, foul-smelling stools further supports this diagnosis.
• Myocardial infarction is unlikely because while the client has chest pain, it is pleuritic and related to inspiration rather than the typical crushing, non-pleuritic chest pain seen in an MI. There is no mention of radiating pain, diaphoresis, or hemodynamic instability.
• Pulmonary edema is unlikely since it typically presents with dyspnea, crackles throughout the lung fields, pink frothy sputum, and signs of fluid overload such as peripheral edema and weight gain. The client’s symptoms do not align with this condition.
• Pulmonary embolism is also unlikely, as it presents with sudden-onset dyspnea, pleuritic chest pain, tachycardia, and often calf swelling or a history of deep vein thrombosis. The client lacks the risk factors and clinical signs of PE.
• Placing the client on contact precautions is necessary because C. difficile is highly contagious and spreads through the fecal-oral route. Gloves and gowns should be used to prevent transmission.
• Obtaining a stool culture is necessary to confirm the presence of C. difficile toxins in the stool, which is essential for accurate diagnosis and treatment.
• Requesting a prescription for an anticoagulant is not necessary because the client does not show any signs of thromboembolic disease such as deep vein thrombosis or pulmonary embolism. Anticoagulation could increase the risk of bleeding in the gastrointestinal tract, which would worsen the diarrhea.
• Requesting a prescription for a diuretic is not needed because the client is more likely to be dehydrated due to diarrhea. Diuretics would exacerbate fluid loss and electrolyte imbalances.
• Restricting fluids is not appropriate because dehydration is a major concern with C. difficile infection. Instead, fluid intake should be encouraged to prevent complications from excessive fluid loss.
• Level of consciousness should be monitored because severe dehydration and electrolyte imbalances can lead to confusion, weakness, and altered mental status. While altered mental status can occur with severe dehydration or sepsis, it is not the primary concern at this stage.
• Potassium level should be monitored because diarrhea can cause significant potassium loss, leading to hypokalemia, which can result in muscle weakness, cardiac arrhythmias, and fatigue.
• Urine output is not the most specific parameter for monitoring C. difficile infection. While dehydration is a concern, tracking electrolyte levels and neurological status is more critical.
• Calf swelling is not relevant since the client does not have signs or risk factors for deep vein thrombosis or pulmonary embolism.
• Weight: C. difficile infection can cause significant fluid loss due to persistent diarrhea, leading to dehydration and weight loss. Tracking daily weight helps assess hydration status and the effectiveness of fluid replacement therapy.