A nurse is planning care for a client who is 4 hr postoperative. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

Give the client aback massage.

Teach the client relaxation techniques.

Assist the client to cough and deep breathe ev

Encourage the client to turn every 4 hr.

Administer PRN analgesics as needed.

Answer and Explanation

Correct Answer : A,B,C,E

A.   Postoperative patients often experience muscle tension and discomfort due to lying in one position for an extended period. A gentle back massage can help relieve muscle stiffness, promote relaxation, and improve circulation. It is a non-invasive comfort measure that can enhance the client's overall well- being.
B.   Teaching relaxation techniques such as deep breathing exercises, guided imagery, or progressive muscle relaxation can help the client manage pain, reduce anxiety, and promote faster recovery. These techniques are beneficial postoperatively as they encourage relaxation and improve overall comfort.
C.   Postoperative clients are at risk of developing respiratory complications such as atelectasis (partial lung collapse) or pneumonia due to shallow breathing or inadequate lung expansion. Coughing and deep breathing exercises help to clear secretions, improve lung function, and prevent respiratory complications. It is typically recommended to perform these exercises every hour to maintain lung expansion and prevent complications.
D.   Encouraging the client to turn every 2 hours (D), not every 4 hours, is essential to prevent pressure ulcers and promote circulation.
E.   Postoperative pain management is essential for the client's comfort and recovery. Pain can interfere with the client's ability to cough, deep breathe, and move effectively, which may increase the risk of complications. Administering analgesics as needed helps to control pain, improve overall comfort, and promote participation in necessary activities such as coughing, deep breathing, and turning.

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Correct Answer is D

Explanation

A. Encouraging adequate fluid intake is important postoperatively to maintain hydration and support normal physiological functions. However, the amount of fluid intake should be within the client's tolerance and as prescribed by the healthcare provider. It helps prevent complications such as dehydration and promotes circulation, which is beneficial for wound healing.

B. While some rest and limited mobility are initially recommended after knee replacement surgery to allow for healing and to prevent complications, prolonged bed rest for 5-7 days is not typically necessary or recommended. Early mobilization and gradual increase in activity are encouraged to prevent complications such as deep vein thrombosis and to promote recovery.
C. Placing a pillow directly under the knee is not recommended as it can lead to decreased range of motion and potential contractures.
D. Cold therapy, such as applying cool compresses, is often used to reduce swelling and pain in the initial postoperative period. It can help manage pain and discomfort and promote comfort for the client.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E"}

Explanation

Correct choices are; Metabolic acidosis:

This can occur due to the client's diarrhea, leading to loss of bicarbonate (HCO3-) through the gastrointestinal tract. The ABG results show a pH slightly below normal (7.33) and a decreased bicarbonate level (19 mEq/L), indicative of metabolic acidosis.

Hypernatremia:

The client's sodium level is elevated at 149 mEq/L (normal range is 136-145 mEq/L). This indicates hypernatremia, which could be due to dehydration from diarrhea and possibly inadequate fluid intake.

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A nurse is planning care for a client who is 4 hr postoperative. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E"}

Explanation

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A nurse is planning care for a client who is 4 hr postoperative. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)