A nurse is caring for a postoperative client. Which intervention should the nurse identify as important to prevent postoperative pulmonary complications?
Place suction equipment at the bedside.
Administer a prophylactic expectorant.
Encourage the use of an incentive spirometer.
Perform range of motion exercises.
The Correct Answer is C
Choice A Reason:
Place suction equipment at the bedside is incorrect. While having suction equipment available is important for emergency situations, it does not directly prevent postoperative pulmonary complications. Suction equipment is used to clear the airway if the client has difficulty breathing or if there is an obstruction.
Choice B Reason:
Administer a prophylactic expectorant is incorrect. Prophylactic expectorants can help in managing secretions, but they are not the primary intervention for preventing postoperative pulmonary complications. The main goal is to promote lung expansion and prevent atelectasis.
Choice C Reason:
Encourage the use of an incentive spirometer is correct. Using an incentive spirometer encourages deep breathing and lung expansion, which helps prevent atelectasis and other postoperative pulmonary complications. It is a key intervention in postoperative care to maintain optimal lung function.
Choice D Reason:
Perform range of motion exercises is incorrect. While range of motion exercises are important for preventing musculoskeletal complications and promoting circulation, they do not directly prevent pulmonary complications. The focus for pulmonary health is on lung expansion and clearing secretions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
When calculating the fluid balance for a client undergoing continuous bladder irrigation (CBI), the irrigation solution must be deducted from the total urine output. This is because the irrigation fluid is not part of the client’s actual urine production but is an additional fluid introduced into the bladder to prevent or remove blood clots and ensure catheter patency. By deducting the irrigation solution from the total urine output, the nurse can accurately determine the client’s true urine output and fluid balance.
Choice B Reason:
Subtracting the irrigation solution from the intravenous flow sheet as output is incorrect. The intravenous flow sheet is used to document fluids administered intravenously, not those introduced into the bladder. Therefore, this choice does not apply to the management of continuous bladder irrigation.
Choice C Reason:
Documenting the intake hourly in the urine output column is also incorrect. The urine output column should reflect the actual urine produced by the client, not the irrigation solution. Including the irrigation solution in this column would lead to an inaccurate representation of the client’s urine output and fluid balance.
Choice D Reason:
Adding the irrigation solution to the oral intake column is incorrect as well. The oral intake column is designated for fluids consumed orally by the client. The irrigation solution is introduced directly into the bladder and should not be recorded as oral intake.
Correct Answer is A
Explanation
Choice A reason: Guided meditation and other nonpharmacological pain interventions can help reduce the perception of pain, which may allow for lower doses of pain management medications. This is beneficial as it can reduce the risk of side effects and dependency associated with higher doses of pain medications1. Studies have shown that integrating nonpharmacological methods like guided meditation can enhance overall pain management and improve the quality of life for patients2.
Choice B reason: Guided meditation is a complementary therapy and is not intended to replace pain medications entirely. While it can significantly aid in pain management, it is typically used alongside pharmacological treatments to provide a holistic approach to pain relief3. Relying solely on guided meditation without appropriate medical supervision and medication can lead to inadequate pain control.
Choice C reason: Guided meditation is not limited to hospital settings or licensed therapists. Many guided meditation resources are available online, through apps, or in community centers, making it accessible to a broader audience4. Patients can practice guided meditation at home, which provides flexibility and convenience in managing chronic pain.
Choice D reason: Pain medications are often prescribed on a regular schedule to maintain consistent pain control, especially in chronic pain conditions. While nonpharmacological interventions can reduce the need for frequent dosing, they do not eliminate the necessity for scheduled pain medications5. It is essential to follow a healthcare provider’s recommendations for medication administration to ensure effective pain management.
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