A nurse is developing a plan of care for a client who is postoperative.
Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?

Encourage the use of an incentive spirometer.

Perform range-of-motion exercises.

Administer an expectorant.

Place suction equipment at the bedside.

Answer and Explanation

The Correct Answer is A

Postoperative care focuses on mitigating risks associated with anesthesia and immobility. This question addresses the prevention of atelectasis and pneumonia by applying knowledge of respiratory mechanics, alveolar expansion, and nursing interventions designed to optimize lung volumes and gas exchange.

Choice A rationale

Incentive spirometry promotes deep breathing and lung expansion, preventing alveolar collapse or atelectasis common after surgery. It encourages sustained maximal inspiration, which increases surfactant production and improves oxygenation, maintaining a normal oxygen saturation of 95 to 100 percent.

Choice B rationale

Range-of-motion exercises primarily prevent musculoskeletal stiffness and deep vein thrombosis by promoting venous return. While important for overall recovery, they do not directly expand lung tissue or prevent pulmonary secretions from accumulating in the bronchioles.

Choice C rationale

Expectorants assist in thinning mucus but do not address the primary postoperative risk of hypoventilation or lung collapse. Preventive care prioritizes mechanical expansion of the lungs over pharmacological management of secretions unless a cough is present.

Choice D rationale

Suction equipment is a reactive measure used when secretions already obstruct the airway. Preventive care focuses on proactive lung expansion techniques rather than the equipment needed for emergency or symptomatic management of existing pulmonary distress.

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Correct Answer is C

Explanation

The management of indwelling urinary catheters requires strict adherence to evidence-based practices to prevent catheter-associated urinary tract infections. This scenario involves applying knowledge of aseptic technique, mechanical drainage patency, and the prevention of bacterial colonization within the urinary system.

Choice A rationale

Regular irrigation increases the risk of introducing pathogens into the sterile urinary tract by breaking the closed drainage system. Irrigation is only indicated for obstructions, such as blood clots, to maintain necessary catheter patency.

Choice B rationale

Daily perineal care should be performed with soap and water rather than antiseptic solutions. Antiseptics can irritate the urethral meatus and disrupt normal flora, potentially increasing the risk of bacterial overgrowth and subsequent infection.

Choice C rationale

Maintaining a prompt and unobstructed flow of urine is vital. Kinks or twists cause urine stasis, which allows bacteria to migrate upward into the bladder, significantly increasing the risk of developing a urinary tract infection.

Choice D rationale

Catheters should only be replaced based on clinical indications, such as obstruction or infection, not on a fixed schedule. Frequent, unnecessary changes increase the risk of urethral trauma and the introduction of exogenous microorganisms.

A. Assess peripheral pulses in the affected extremities. B. Irrigate the entrance and exit wounds. C. Place the client on continuous cardiac telemetry monitoring. D. Administer IV opioid pain medication.

Correct Answer is C

Explanation

Electrical burns require understanding the path of current through the body. Because electricity follows the path of least resistance, it often travels through the heart. This necessitates applying knowledge of cardiac rhythm disturbances and immediate diagnostic prioritization.

Choice A rationale

Checking pulses is important to assess for compartment syndrome or vascular damage in the right hand and left foot. However, it is secondary to assessing the heart, as electrical current can cause immediate, fatal cardiac arrest.

Choice B rationale

Irrigating wounds is part of standard burn care but is not the priority for electrical injuries. The surface wounds often mask extensive internal tissue damage. Addressing potential cardiac conduction issues must occur before performing local wound cleansing.

Choice C rationale

Electrical current passing between hands and feet frequently crosses the heart. This can cause immediate dysrhythmias or delayed cardiac irritability. Continuous telemetry is vital to monitor for life-threatening changes in the heart's electrical activity and rhythm.

Choice D rationale

While the client may experience pain, the report of chest tightness and lightheadedness suggests a cardiac or hemodynamic event. Administering opioids before stabilizing the cardiac status could mask symptoms or further complicate the clinical assessment process..

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A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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A nurse is developing a plan of care for a client who is postoperative.
Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?