A nurse is providing teaching to a school-age child who has asthma about using an albuterol metered-dose inhaler. Which of the following instructions should the nurse include?

The correct answers are A, B, and D.

Choice A reason:

Removing an indwelling urinary catheter when it is no longer indicated is a standard postoperative care practice. It helps to reduce the risk of urinary tract infections (UTIs), which are common complications associated with prolonged catheter use. The normal practice is to remove the catheter as soon as the patient can use the bathroom independently or when medically advised.

Choice B reason:

Elevating the affected limb at chest level can help reduce swelling and improve venous return. This is particularly important after surgery involving the lower extremities to prevent edema and promote circulation. Proper elevation assists in managing pain and preventing complications such as deep vein thrombosis (DVT).

Choice C reason:

Assisting with ambulation from bed to chair immediately after surgery may not be appropriate, especially if the adolescent has had surgery on the lower extremity. It is essential to wait for the physician's evaluation and specific instructions regarding weight-bearing and movement post-surgery.

Choice D reason:

Performing neurovascular assessments every hour is crucial after surgery on an extremity. This involves checking for sensation, motor function, color, temperature, capillary refill, and pulse strength. The normal capillary refill time is less than 2 seconds; a refill time of 4 seconds, as noted in the assessment, is abnormal and warrants close monitoring. Frequent assessments help in early detection of complications such as compartment syndrome.

Choice E reason:

Applying warm packs to the right extremity for the first 24 hours post-surgery is not recommended. Warm packs can increase circulation to the area, potentially increasing swelling and bleeding. Instead, cold packs are usually applied to reduce swelling and provide pain relief. The use of warm packs can be considered after the initial 24-hour period, depending on the surgeon's instructions and the wound's response.

- A. Palpate the degree of edema. This is incorrect because palpating the degree of edema requires clinical judgment and skill, which are beyond the scope of practice of an AP. -

B. Regulate IV pump fluid rate. This is incorrect because regulating IV pump fluid rate is a nursing responsibility that involves calculating and adjusting the infusion rate based on the client's condition and orders.

- C. Measure the client's daily weight. This is correct because measuring the client's daily weight is a routine task that can be delegated to an AP, as long as the nurse provides clear instructions and monitors the results. The client's daily weight is an indicator of fluid balance and can help evaluate the effectiveness of treatment.

- D. Assess the client's vital signs. This is incorrect because assessing the client's vital signs requires interpretation and analysis of data, which are nursing functions that cannot be delegated to an AP.