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?

Administer the antibiotic earlier than scheduled.

Administer pain medication.

Have the client use the incentive spirometer.

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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Correct Answer is ["250"]

Explanation

To calculate the rate at which the nurse should set the IV pump in mL/hr, we need to determine the infusion rate.

The client is receiving 1 gram of antibiotic in 500 ml of fluid over 2 hours. To find the rate in mL/hr, we divide the total volume (500 ml) by the total time (2 hours):

Rate = Volume / Time Rate = 500 ml / 2 hours Rate = 250 ml/hr

Therefore, the nurse should set the IV pump at a rate of 250 mL/hr.

A. Take a brisk walk after eating. B. Avoid excessive sugar and carbohydrates. C. Increase fluid intake with meals. D. Take the proton pump inhibitors as prescribed.

Correct Answer is B

Explanation

Dumping syndrome is a common complication after Gastric Bypass surgery, where food moves too quickly from the stomach to the small intestine. It occurs when the undigested contents of the stomach are "dumped" rapidly into the small intestine, leading to symptoms such as nausea, vomiting, abdominal cramps, diarrhea, lightheadedness, and sweating.

To manage dumping syndrome, it is important for the client to avoid foods and beverages that are high in sugar and carbohydrates. Consuming these types of foods can trigger rapid gastric emptying and exacerbate the symptoms. Instead, the client should focus on a well-balanced diet that includes lean proteins, healthy fats, and complex carbohydrates.

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Naxlex Comprehensive Predictor Exams

The client is to receive an antibiotic 1 gram in 500 ml of fluid intravenously over 2 hours. At what rate will the nurse set the IV pump in mL/hr.? (Answer as whole number)

Correct Answer is ["250"]

Explanation

In order to prevent dumping syndrome after Gastric Bypass surgery, the nurse will instruct the client to....

Correct Answer is B

Explanation

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