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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A WBC count of 1,300/mm³ indicates severe leukopenia, a contraindication for clozapine due to its risk of agranulocytosis. Low white cells increase infection risk, requiring immediate discontinuation or monitoring per FDA guidelines, making this the critical finding to identify.
Choice B reason: Hemoglobin of 16 g/dL is within normal range (14-18 g/dL) and does not contraindicate clozapine use. Normal hemoglobin supports adequate oxygen transport, so this finding is unremarkable and incorrect for identifying a contraindication.
Choice C reason: Fasting blood glucose of 124 mg/dL indicates mild elevation but is not a contraindication for clozapine, which may worsen glucose control. Monitoring is needed, but this level does not preclude use, making it incorrect.
Choice D reason: Platelet count of 200,000/mm³ is normal (150,000-450,000/mm³) and does not contraindicate clozapine. Normal platelets ensure proper clotting, so this finding is not a concern for clozapine administration, making it incorrect.
Correct Answer is C
Explanation
Choice A reason: Raising the head of the bed during transfer does not prioritize ergonomic principles. It may strain the nurse’s back or misalign the client, increasing injury risk. Ergonomics focuses on neutral spine alignment and mechanical aids to reduce physical strain during client transfers.
Choice B reason: Placing pillows under the head is a comfort measure, not an ergonomic principle. Ergonomics emphasizes reducing musculoskeletal strain through proper mechanics or devices. Pillows do not directly prevent nurse injuries, unlike transfer devices that minimize physical effort during client movement.
Choice C reason: Using a lateral transfer device, like a slide board, aligns with ergonomic principles by reducing manual lifting and spinal strain. It prevents back injuries, ensuring safe client transfer. This evidence-based practice supports occupational health guidelines, minimizing musculoskeletal risks for nurses during patient handling.
Choice D reason: Standing close during ambulation ensures client stability but is not a primary ergonomic principle. Ergonomics focuses on equipment and mechanics to reduce strain, not proximity, which addresses patient safety more than nurse injury prevention during transfers or repositioning tasks.
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