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
Thinking critically is a fundamental skill in nursing. It involves the ability to question, analyze, and evaluate care processes and outcomes. Critical thinking allows nurses to make informed decisions, prioritize tasks, and solve problems efficiently and effectively, which ultimately leads to safe, quality, patient-centered care.
Choice B rationale
Evaluating outcomes at the start of the shift is not typically recommended. Instead, continuous evaluation throughout the shift is more beneficial. This allows for timely interventions and adjustments to the care plan as needed.
Choice C rationale
Communication is a vital aspect of patient-centered care. Effective communication ensures that all members of the healthcare team, including the patient, are informed about the patient’s care plan. This promotes collaboration, improves patient outcomes, and enhances patient satisfaction.
Choice D rationale
Planning and reporting outcomes are crucial components of the nursing process. They enable the tracking of progress, facilitate communication among healthcare providers, and ensure that care is aligned with the patient’s goals.
Choice E rationale
Evaluating outcomes at the end of the shift is important as it provides an opportunity to assess the effectiveness of interventions, make necessary adjustments to the care plan, and ensure continuity of care.

Choice A rationale
Auscultating the lungs for the presence of breath sounds is a priority action following endotracheal intubation. This helps to confirm correct tube placement and assess for complications such as a pneumothorax.
Choice B rationale
While it is important to ensure that the pulse oximetry is greater than 95% to confirm adequate oxygenation, this is not the priority action. The nurse should first confirm correct tube placement by auscultating lung sounds.
Choice C rationale
Assessing the baseline level of consciousness is important, but it is not the priority action following endotracheal intubation.
Choice D rationale
Assessing for the presence of circumoral cyanosis can indicate hypoxia, but it is not the priority action. The nurse should first confirm correct tube placement by auscultating lung sounds.