A nurse is planning care for a male client who is postoperative following a hernia repair. Which of the following actions should the nurse include in the plan?
Restrict fluids to 1,200 mL per day.
Encourage deep breathing exercises every 2 hours.
Apply a warm compress to the surgical site.
Limit ambulation for 48 hours post-surgery.
The Correct Answer is B
Choice A reason: Restricting fluids to 1,200 mL per day is not indicated post-hernia repair unless specific conditions like heart failure exist. Adequate hydration supports recovery and prevents complications like constipation. This restriction is arbitrary and potentially harmful, making it an incorrect plan component.
Choice B reason: Encouraging deep breathing exercises every 2 hours prevents pulmonary complications like atelectasis or pneumonia, common risks post-hernia repair due to anesthesia and pain-limited breathing. This promotes lung expansion and oxygenation, aligning with evidence-based postoperative care, making it the correct intervention.
Choice C reason: Applying a warm compress to the surgical site is not recommended, as it may increase swelling or risk infection in the early postoperative period. Cool compresses, if needed, reduce edema. This intervention lacks evidence and could harm healing, making it inappropriate.
Choice D reason: Limiting ambulation for 48 hours delays recovery, as early mobility post-hernia repair reduces complications like thromboembolism and promotes healing. Patients are typically encouraged to walk within hours, making this restriction counterproductive and against standard postoperative protocols, thus incorrect.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Varicella, a viral infection, is not treated with antibiotics, which target bacteria. Returning to school after 24 hours of antibiotics is incorrect, as contagiousness persists until lesions crust, typically 5-7 days, risking transmission if the child returns prematurely.
Choice B reason: A negative titer result indicates immunity or resolved infection but is not a practical criterion for school return. Varicella contagiousness depends on lesion crusting, not serology, which is complex and unnecessary when clinical signs confirm reduced infectivity in affected children.
Choice C reason: Fever subsidence does not ensure non-contagiousness in Varicella. The virus spreads via respiratory droplets and lesions until crusted. Allowing return based on fever ignores transmission risk, as active lesions remain infectious, potentially spreading the virus in school settings.
Choice D reason: Varicella is contagious until lesions crust over, typically 5-7 days post-rash. Crusting indicates the end of viral shedding, ensuring safety for school return. This aligns with infection control guidelines, preventing transmission via contact or respiratory routes in communal settings.
Correct Answer is B
Explanation
Choice A reason: Warming blood products prevents hypothermia during transfusion but is not the priority in a trauma patient. Airway management takes precedence, as oxygenation is critical to survival. Administering blood products comes later in the trauma algorithm, after securing the airway and stabilizing breathing, making this action secondary.
Choice B reason: Establishing a patent oral airway is the first priority in trauma care, following the ABCs (Airway, Breathing, Circulation). A clear airway ensures oxygenation, critical for preventing hypoxia in a patient with multiple injuries. Without a patent airway, other interventions are ineffective, as oxygen delivery is essential for survival and organ function.
Choice C reason: Creating a sterile field for wound care is important to prevent infection but is not the first priority in a trauma patient. Airway and breathing take precedence, as immediate life-threatening issues like hypoxia or shock must be addressed before wound care, making this action lower in priority.
Choice D reason: Administering IV fluids to maintain blood pressure is part of the circulation phase in trauma care but follows airway and breathing stabilization. Without a patent airway, fluid administration cannot address hypoxia, a primary cause of mortality in trauma. This action is secondary to ensuring airway patency.
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