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 D
Explanation
Choice A rationale:
Initiating IV access on the palmar side of the client's wrist is not recommended. This area has many delicate structures and is prone to complications such as nerve damage. Choosing a safer, larger vein proximal to the wrist is a better practice.
Choice B rationale:
Inserting a larger gauge IV catheter is not necessary unless the client's condition or prescribed therapy specifically requires it. Using an unnecessarily large catheter can cause discomfort and increase the risk of complications, such as phlebitis.
Choice C rationale:
Choosing the client's dominant arm for IV access whenever possible is not a universally appropriate guideline. The choice of the arm should depend on the condition of the veins and the individual patient's circumstances. The nurse should assess both arms and choose the one with the most suitable and accessible veins.
Choice D rationale:
Selecting a site proximal to previous venipuncture sites is the correct action. Repeated venipuncture in the same area can cause phlebitis and compromise the integrity of the veins. Selecting a new site proximal to previous punctures helps to preserve vein health and reduce the risk of complications.
Correct Answer is A
Explanation
a. Improves muscle strength.
Explanation:
Neostigmine is a medication used in the treatment of myasthenia gravis (MG). It belongs to a class of drugs called cholinesterase inhibitors. Neostigmine works by inhibiting the breakdown of acetylcholine, a neurotransmiter involved in muscle contraction. In MG, there is a decrease in the amount of acetylcholine available at the neuromuscular junction, leading to muscle weakness and fatigue.
By inhibiting the breakdown of acetylcholine, neostigmine helps to increase the concentration of acetylcholine at the neuromuscular junction. This, in turn, improves muscle strength and can alleviate the symptoms of weakness and fatigue associated with MG.
Option b, destroying the antibodies that cause MG, is not accurate. Myasthenia gravis is an autoimmune disorder characterized by the presence of antibodies that interfere with neuromuscular transmission.
Neostigmine does not directly target or eliminate these antibodies.
Option c, enhancing immune system function, is not accurate either. Neostigmine primarily acts on the neuromuscular junction to improve muscle strength and does not have a direct effect on immune system function.
Option d, preventing excessive coughing, is not the primary action of neostigmine. While increased muscle strength may indirectly improve respiratory function and reduce coughing in individuals with myasthenia gravis, it is not the primary indication or action of neostigmine.
Therefore, the most accurate information to include in teaching about neostigmine for a client with myasthenia gravis is that it improves muscle strength.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.