A nurse is developing a plan of care for an 80-year-old client who is postoperative. This client has a 38 pack-year smoking history. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?

Place suction equipment at the bedside.

Perform range of motion (ROM) exercises.

Administer an expectorant.

Encourage the use of incentive spirometry.

Answer and Explanation

The Correct Answer is D

Choice A reason: Placing suction equipment at the bedside is a preparatory measure but not a preventive intervention for pulmonary complications.

Choice B reason: Performing ROM exercises is beneficial for overall mobility but does not directly prevent pulmonary complications.

Choice C reason: Administering an expectorant may help clear secretions but is not the primary preventive measure for pulmonary complications.

Choice D reason: Encouraging the use of incentive spirometry is a proven intervention to prevent pulmonary complications by promoting lung expansion and preventing atelectasis, especially in patients with a history of smoking.

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Correct Answer is C

Explanation

Choice A reason : While maintaining a stable ECG rhythm is important, it is not the highest priority. The primary concern is to address life-threatening complications.

Choice B reason : Educating the patient about the causes and eﬀects of coronary heart disease (CHD) or coronary artery disease (CAD) is important for long-term management but is not the immediate priority during acute care.

Choice C reason : Adequate relief of pain is the highest priority in the care of a patient with AMI. Pain is an indicator of ongoing ischemia and can increase the workload of the heart, thereby worsening the condition.

Choice D reason (AMI): While bedrest is part of the care plan, it is not the highest priority compared to pain relief, which has direct implications on the patient's immediate physiological status.

A. As soon as the nurse can prepare the client and the administration set B. 2 hours after obtaining blood from the blood bank C. When the client has finished eating his Burger King lunch D. When the client states he is ready to start the infusion

Correct Answer is A

Explanation

Choice A reason: Packed RBCs should be transfused as soon as possible once the nurse has prepared everything necessary for the transfusion.

Choice B reason: Waiting 2 hours after obtaining the blood is not necessary and could delay needed treatment.

Choice C reason: The client's mealtime should not delay the transfusion of blood, which is a time-sensitive medical treatment.

Choice D reason: While the client's readiness is important, it should not unduly delay the transfusion if the client is medically stable and the transfusion is necessary.

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A nurse is developing a plan of care for an 80-year-old client who is postoperative. This client has a 38 pack-year smoking history. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?

Nursing Test Bank

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A nurse is developing a plan of care for an 80-year-old client who is postoperative. This client has a 38 pack-year smoking history. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?

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