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.

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A reason: Smoked salmon is high in tyramine, which phenelzine, an MAOI, prevents from being metabolized. This risks hypertensive crisis due to norepinephrine release, potentially causing stroke or cardiovascular complications. Avoiding tyramine-rich foods is critical for safety in clients on MAOI therapy.
Choice B reason: Cottage cheese is low in tyramine, safe for phenelzine users. Unlike aged cheeses, fresh dairy poses minimal risk of hypertensive crisis, as it lacks significant tyramine content. MAOIs require avoiding high-tyramine foods, making cottage cheese an acceptable dietary choice for these clients.
Choice C reason: Grapefruit affects CYP450 enzymes, interacting with some drugs, but is not contraindicated with phenelzine. It lacks significant tyramine, so it does not trigger hypertensive crises. Avoidance is unnecessary, as it does not impact MAOI metabolism or related cardiovascular risks.
Choice D reason: Fresh apples are low in tyramine and safe for phenelzine users. MAOIs require avoiding tyramine-rich foods like aged meats, but fresh fruits do not cause hypertensive crises, as they lack amino acids interacting with MAOI metabolism, making them safe for consumption.

A. Place the client upright on a donut-shaped cushion. B. Turn and reposition the client every 15 minutes while sitting. C. Apply a moisture-barrier cream to the affected area. D. Turn and reposition the client every 3 hours while in bed.

Correct Answer is B

Explanation

Choice A rationale: Donut-shaped cushions are contraindicated because they create a ring of high pressure that restricts blood flow to the central area. This can worsen tissue ischemia and accelerate skin breakdown.

Choice B rationale: Clients with paraplegia sitting in a chair should be repositioned every 15 minutes to relieve pressure. Frequent shifts are necessary because sitting exerts higher pressure on the ischial tuberosities than lying down.

Choice C rationale: Moisture-barrier creams are used to protect skin from incontinence or wound drainage. Nonblanchable erythema indicates a stage 1 pressure injury, which requires pressure relief rather than a topical moisture barrier.

Choice D rationale: While in bed, the standard of care is to turn and reposition the client at least every 2 hours. A 3-hour interval is too long and increases the risk of further tissue damage.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has a depressive disorder and a new prescription for phenelzine. Which of the following foods should the nurse instruct the client to avoid?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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