A nurse is providing a handoff report to the oncoming shift nurse. Which of the following actions should the nurse take to ensure continuity of client care?

A. Administer acetaminophen: Acetaminophen is useful for fever, but it does not improve respiratory status. The priority is to promote lung expansion and prevent complications like atelectasis, which is achieved through deep breathing, coughing, and ambulation.

B. Instruct the client to use the incentive spirometer five times per hour: Using the incentive spirometer frequently helps to expand the lungs and reduce the risk of atelectasis, a common postoperative complication. This intervention encourages deep breathing and improves oxygenation, which is essential for the client’s respiratory status.

C. Ambulate the client 30 min after administering analgesia: Ambulation promotes deep breathing and lung expansion, and it helps to mobilize secretions. Administering analgesia before ambulation ensures that the client is comfortable enough to participate in this activity.

D. Encourage the client to cough and breathe deeply: Encouraging deep breathing and coughing helps clear secretions from the lungs and promotes better oxygenation. This helps prevent respiratory complications especially after surgery when lung expansion is compromised.

E. Administer ondansetron: While ondansetron is necessary for controlling nausea, it does not directly improve the client’s respiratory status. However, if nausea is under control, the client may be more willing to participate in activities that promote lung expansion.

F. Administer supplemental oxygen: The current oxygen saturation of 92% is slightly low but not critical. The priority is to improve the client’s respiratory status through physical activity and breathing exercises before considering oxygen supplementation.

G. Encourage the client to splint the abdomen: Splinting the abdomen with a pillow while coughing or deep breathing reduces discomfort, especially after abdominal surgery. This technique helps the client engage in deep breathing and coughing more effectively.

A. Set the suction device to 120 mm Hg: For nasopharyngeal suctioning in adults, the suction pressure should typically be set between 100 and 120 mm Hg to prevent injury to the mucous membranes while effectively clearing secretions.

B. Apply suction to the catheter during insertion: Suction should not be applied during insertion of the catheter, as this can cause trauma to the mucous membranes. Suctioning should only occur when the catheter is in the appropriate position and being withdrawn.

C. Have the client tuck his chin to his chest during suctioning: The client should not tuck the chin to the chest during suctioning. Instead, the client should be asked to either cough or breathe normally. Tucking the chin may obstruct the airway and make suctioning difficult.

D. Apply a petroleum-based lubricant to the catheter: Petroleum-based lubricants should not be used as they can cause a fire hazard when oxygen is present. Instead, a water-soluble lubricant should be applied to the catheter if needed.