A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the following actions is the nurse's priority?
Assess fluid intake every 24 hr.
Ambulate three times a day.
Assist with deep breathing and coughing.
Monitor the incision site for findings of infection.
The Correct Answer is C
A. Assessing fluid intake every 24 hr is important for a postoperative client, but it is not the priority action. The nurse should monitor fluid intake and output more frequently, such as every 8 hr or every shift, to detect any imbalances or complications.
B. Ambulating three times a day is beneficial for a postoperative client, but it is not the priority action. The nurse should encourage early and frequent ambulation to promote circulation, prevent thromboembolism, and enhance bowel function, but only after ensuring that the client is stable and has adequate pain control.
C. Assisting with deep breathing and coughing is the priority action for a postoperative client who had abdominal surgery. The nurse should help the client perform these exercises every 1 to 2 hr to prevent atelectasis, pneumonia, and respiratory failure, which are common and serious complications after abdominal surgery.
D. Monitoring the incision site for findings of infection is important for a postoperative client, but it is not the priority action. The nurse should inspect the wound for signs of infection, such as redness, swelling, warmth, drainage, or odor, but this can be done during routine dressing changes or as needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Oliguria. This is incorrect because oliguria, or decreased urine output, is a sign of fluid volume deficit, not fluid volume overload.
B. Bradycardia. This is incorrect because bradycardia, or slow heart rate, is not a typical sign of fluid volume overload, unless the client has a cardiac condition that affects the heart's response to fluid overload.
C. Dyspnea. This is correct because dyspnea, or difficulty breathing, is a common sign of fluid volume overload, as excess fluid accumulates in the lungs and impairs gas exchange.
D. Poor skin turgor. This is incorrect because poor skin turgor, or decreased elasticity of the skin, is a sign of dehydration, not fluid volume overload.
Correct Answer is C
Explanation
A. Incorrect. Organizing the work environment is an important step of the time management process, but it is not the priority. The nurse manager should first identify the activities that need to be done before organizing them.
B. Incorrect. Delegating assigned tasks appropriately is an important step of the time management process, but it is not the priority. The nurse manager should first determine which tasks can be delegated and which ones require their direct involvement before assigning them to others.
C. Correct. Making a list of activities to complete is the priority step of the time management process, as it helps the nurse manager to identify and prioritize their goals and responsibilities.
D. Incorrect. Rewarding yourself for accomplishing goals is an important step of the time management process, but it is not the priority. The nurse manager should first complete the tasks that are essential and urgent before rewarding themselves for their achievements.
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