A nurse is caring for a postoperative client experiencing shallow respirations and refusing to cough or get out of bed to the chair.

The nurse should educate the client about the increased risk of which complication?

Choice A rationale
While the application of anti-embolism stockings can be beneficial in preventing deep vein thrombosis in postoperative patients, it is not the most prioritized nursing intervention in the immediate postoperative period for a patient who has undergone a left pneumonectomy. The immediate postoperative period after a pneumonectomy is critical for monitoring and managing potential complications such as respiratory distress, hemorrhage, and bronchopleural fistula.
Choice B rationale
The use of the incentive spirometer is an important nursing intervention for postoperative patients to promote lung expansion and prevent atelectasis. However, in the immediate postoperative period following a pneumonectomy, the priority is to monitor for complications and ensure the stability of the patient.
Choice C rationale
Assessment of the chest tube and pleur-evac is the most prioritized nursing intervention in the immediate postoperative period for a patient who has undergone a left pneumonectomy. After a pneumonectomy, a chest tube is placed to drain air, blood, and fluid from the pleural space to allow the remaining lung to re-expand. It is crucial to monitor the chest tube system for proper functioning and to assess for complications such as excessive bleeding, infection, or pneumothorax.
Choice D rationale
Repositioning the patient in bed is a standard nursing intervention in postoperative care to enhance comfort, promote lung expansion, and prevent complications such as pressure ulcers and deep vein thrombosis. However, it is not the most prioritized intervention in the immediate postoperative period following a pneumonectomy, where monitoring for respiratory complications and ensuring the stability of the patient are paramount.

Choice A rationale
Reporting the absence of spontaneous respirations is important, but it is not the priority action. The patient is on mechanical ventilation, so the absence of spontaneous respirations is expected.
Choice B rationale
Encouraging the patient to attempt to breathe on their own is not the priority action. The patient is receiving mechanical ventilation, which means they are likely unable to breathe adequately on their own.
Choice C rationale
Providing passive range-of-motion exercises is important for overall patient mobility and prevention of complications such as deep vein thrombosis, but it is not the priority action in this case.
Choice D rationale
Responding to ventilator alarms is the priority action. Alarms may indicate a change in the patient’s condition or a problem with the ventilator. Immediate response is necessary to ensure the patient’s safety.