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A nurse is caring for a client who is 1-day post-total hip replacement surgery. Assessment findings are as follows.

Assessment

  • Vital Signs BP 112/68 mmHg
  • Heart rate 75 beats/min. Respirations 18 breaths/min 02 saturation 90%, room air Surgical site clean, dry, intact
  • Lung sounds clear upper lobes, diminished lower lobes.
  • Pain 2/10

Which action by the nurse is most appropriate at this time?

A.

Administer the antibiotic earlier than scheduled.

B.

Administer pain medication.

C.

Have the client use the incentive spirometer.

D.

Change the dressing over the wound.

Answer and Explanation

The Correct Answer is C

The assessment findings indicate that the client has diminished lung sounds in the lower lobes, suggesting potential postoperative atelectasis or decreased air movement in the lungs. Using an incentive spirometer can help improve lung expansion and prevent respiratory complications such as pneumonia. It is important to address this issue promptly to prevent further deterioration of lung function.

Administering pain medication may be necessary depending on the client's level of pain, but addressing the respiratory issue takes priority in this situation.

Administering the antibiotic earlier than scheduled or changing the dressing over the wound may not be indicated based on the provided assessment findings.

Therefore, having the client use the incentive spirometer is the most appropriate action at this time to promote optimal lung function and prevent respiratory complications.


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Related Questions

Correct Answer is ["Lithotripsy"," Encourage increased fluid intake"]

Explanation

Lithotripsy and Encourage increased fluid intake are the most important interventions.

Correct Answer is ["B","C","D","E"]

Explanation

The initial bundle of care in sepsis includes the following:

  • Obtain blood cultures: Blood cultures help identify the specific microorganism causing the infection, which is important for guiding appropriate antibiotic therapy.
  • Administer broad-spectrum antibiotics: Early administration of antibiotics is crucial in sepsis to target the suspected or likely infectious organisms. Broad-spectrum antibiotics cover a wide range of potential pathogens until more specific information from culture results is available.
  • Obtain lactate levels: Measuring lactate levels helps assess tissue perfusion and can be used as an indicator of the severity of sepsis. Elevated lactate levels are associated with tissue hypoperfusion and increased mortality.
  • Administer IV fluid bolus: Early aggressive fluid resuscitation is an essential component of sepsis management. Administering intravenous fluids helps restore intravascular volume and improve tissue perfusion.
  • Administration of vasopressors: Especially in the setting of hypotension and to maintain MAP above 65mmHg.

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