A nurse is caring for a client in an acute care setting.

Exhibits

Complete the following sentence by using the list of options.

The client is at risk for

_________

  as evidenced by

_______

.

A. Place the client's hands in warm water: This action can stimulate the client’s natural reflex to urinate. The warm water helps relax the muscles involved in urination.

B. Administer a benzodiazepine: Incorrect. Benzodiazepines are not indicated for difficulty urinating postpartum and can cause unnecessary sedation.

C. Place an ice pack on the client's perineum: Incorrect. An ice pack is typically used to reduce swelling or discomfort, but it is not a primary intervention for urinary retention.

D. Perform a fundal massage: Incorrect. Fundal massage is performed to assess uterine tone, not for urinary retention.

A. Perform chest percussion and vibration. Chest percussion and vibration help loosen and mobilize mucus in the airways, which is essential for clients with productive cough and a history of smoking-related respiratory issues. This intervention facilitates effective expectoration and improves breathing.

B. Place the client in a supine position. Placing the client in a supine position can worsen shortness of breath, especially in individuals with respiratory distress. The client should be positioned upright or in a high-Fowler's position to facilitate lung expansion.

C. Instruct the client to perform diaphragmatic breathing. Diaphragmatic breathing helps improve lung expansion, reduce the work of breathing, and promote relaxation. This technique is particularly useful for clients with an irregular breathing pattern and anxiety.

D. Assess the client's breath sounds. Continuous assessment of breath sounds is critical to monitor the effectiveness of interventions, such as oxygen therapy and nebulization, and to detect any worsening of respiratory status.

E. Restrict the client's fluid intake. Fluid intake should not be restricted unless contraindicated, as hydration helps thin mucus, making it easier to expectorate. This is particularly important for clients with a productive cough.

F. Increase oxygen flow rate to 4 L/min. Increasing the oxygen flow rate beyond 2 L/min requires caution in clients with chronic obstructive pulmonary disease (COPD) or similar conditions, as higher oxygen levels can suppress their respiratory drive. Oxygen therapy should be titrated carefully based on the provider's prescription and monitoring of oxygen saturation.