A nurse is using the domains of learning to provide teaching to a client who has diabetes mellitus. Which of the following actions should the nurse take to utilize psychomotor learning?

Rationale

A. Instruct the client to use the incentive spirometer five times per hour: Frequent use of the incentive spirometer promotes lung expansion, prevents atelectasis, and improves oxygenation postoperatively, especially when lung sounds are diminished.

B. Administer ondansetron: Ondansetron addresses nausea but does not directly improve respiratory status. While important for comfort, it is not a primary intervention for pulmonary function.

C. Encourage the client to splint the abdomen: Splinting the incision during coughing or deep breathing reduces pain, allowing the client to perform respiratory exercises effectively and decrease the risk of atelectasis or hypoventilation.

D. Encourage the client to cough and breathe deeply: Deep breathing and coughing mobilize secretions, enhance alveolar ventilation, and prevent postoperative pulmonary complications, which is critical given the client’s diminished lung sounds and shallow respirations.

E. Administer supplemental oxygen: Supplemental oxygen can help improve oxygen saturation in clients with hypoxemia, as indicated by the drop to 92% on room air.

F. Ambulate the client 30 min after administering analgesia: Early ambulation enhances lung expansion, promotes circulation, and helps prevent pulmonary complications. Providing analgesia beforehand minimizes pain and encourages participation.

G. Administer acetaminophen: Acetaminophen may reduce fever and mild pain but does not directly improve respiratory status or lung expansion, so it is not a primary intervention in this scenario.

Rationale

A. Poor skin turgor: Poor skin turgor is typically a sign of fluid volume deficit, not excess. In fluid overload, the skin may appear edematous or stretched rather than dehydrated. Assessing turgor helps differentiate between dehydration and overhydration.

B. Thready pulse: A thready, weak pulse is often associated with hypovolemia due to reduced circulating volume. In fluid volume excess, pulses are usually full and bounding because of increased intravascular pressure. Pulse quality provides insight into circulatory status.

C. Crackles in lung bases: Crackles heard in the lower lung fields indicate pulmonary fluid accumulation, a common finding in fluid volume excess. Excess intravascular fluid can leak into the alveoli, causing impaired gas exchange and respiratory symptoms. Auscultation of crackles helps identify pulmonary edema early.

D. Flat neck veins: Flat neck veins are associated with low central venous pressure, typically seen in dehydration or hypovolemia. In fluid overload, neck veins are often distended due to increased venous pressure. Jugular vein assessment is a key indicator of intravascular volume status.