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. Bowel sounds are hypoactive in all four quadrants, which is expected after an appendectomy due to anesthesia and decreased peristalsis. This is not a finding that needs to be reported to the provider.
• B. Oxygen saturation is 93% on room air, which is below the normal range of 95% to 100%. This could indicate impaired gas exchange, respiratory depression, or infection. This is a finding that needs to be reported to the provider.
• C. Nausea is a common feature of appendicitis and should go away with appendectomy. This finding should, therefore, be reported to the healthcare provider.
• D. Vomiting is also a common side effect of morphine and anesthesia, and can be managed with antiemetics and fluids. This is not a finding that needs to be reported to the provider unless it persists or interferes with oral intake.
• E. Pain level is 6 on a scale of 0 to 10.The client received morphine as prescribed at 1815, and the pain level is still significant. This isa finding that needs to be reported to the provider
• F. Heart rate is 110/min, which is above the normal range of 60 to 100/min. This could indicate pain, anxiety, dehydration, infection, or bleeding. This is a finding that needs to be reported to the provider.
• G. Incision characteristics are clean and dry, which is expected after an appendectomy. However, the nurse should monitor for signs of infection such as redness, swelling, warmth, drainage, or odor. This is a finding that needs to be reported to the provider if any signs of infection are present.
• H. Lungs sounds are clear on auscultation, which is expected after an appendectomy. However, the nurse should encourage deep breathing and coughing exercises to prevent atelectasis and pneumonia. This is a finding that needs to be reported to the provider if any abnormal lung sounds are heard such as crackles, wheezes, or diminished breath sounds.