A nurse is updating a postoperative client's plan of care. The nurse should include which of the following as the priority interventions?
Reposition the client frequently.
Instruct the client to use the incentive spirometer.
Increase the amount of time the client spends out of bed each day.
Ensure the client consumes an adequate amount of fluids.
The Correct Answer is B
A. Reposition the client frequently: While repositioning is important for preventing pressure ulcers and maintaining comfort, it may not be the priority immediately postoperatively compared to other interventions.
B. Instruct the client to use the incentive spirometer: This is the correct answer. Incentive spirometry helps prevent atelectasis and respiratory complications postoperatively, making it a priority intervention to include in the plan of care.
C. Increase the amount of time the client spends out of bed each day: Early ambulation is important for preventing complications such as deep vein thrombosis and pneumonia, but it may not be the priority immediately postoperatively depending on the client's condition and surgical procedure.
D. Ensure the client consumes an adequate amount of fluids: While hydration is important for postoperative recovery, ensuring adequate fluid intake may not be the priority compared to interventions aimed at preventing respiratory complications such as atelectasis.
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Related Questions
Correct Answer is D
Explanation
A. Do-not-resuscitate status: While important for the client's ongoing care, the do-not-resuscitate status may not be relevant to include in the discharge documentation unless it has changed during the course of the client's hospitalization.
B. Acuity level of client care: While relevant for internal communication among healthcare providers, the acuity level of client care may not be necessary to include in the discharge documentation for the receiving healthcare team.
C. Laboratory test results: While relevant for the client's medical history and ongoing care, specific laboratory test results may not always be necessary to include in the discharge documentation unless they are critical for the client's follow-up care.
D. Reconciled medications: This is the correct answer. Reconciled medications, including a list of medications the client was taking before admission, medications administered during the hospital stay, and any changes made to the medication regimen, are essential for ensuring continuity of care and safe medication management after discharge.
Correct Answer is C
Explanation
A. Nonmaleficence: This principle emphasizes the obligation to avoid causing harm. While the absence of a gait belt could have contributed to the client's fall, the primary ethical concern in this scenario is related to truthfulness and honesty in documentation rather than solely avoiding harm.
B. Fidelity: Fidelity refers to the obligation to fulfill commitments and obligations. While accurate documentation is part of professional integrity, the primary ethical issue in this scenario is related to honesty and accuracy in reporting rather than fidelity to commitments.
C. Veracity: This is the correct answer. Veracity refers to truthfulness and honesty. The charge nurse should ensure that incident reports accurately reflect the circumstances surrounding a client's fall, including the absence of a gait belt, to maintain ethical standards and promote patient safety.
D. Beneficence: Beneficence involves acting in the best interest of the patient and promoting their well-being. While the absence of a gait belt may have compromised the client's safety, the primary ethical issue in this scenario is related to truthfulness in reporting rather than directly promoting the client's well-being.
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