A nurse on a medical-surgical unit is admitting a client.

Exhibits

Click to highlight the action that would be appropriate for the care of the client. Each body system may support more than 1 potential action. To deselect an action, click on the action again.

Body System	Action
Cardiopulmonary	Inform client to achieve two to four breaths per session when using incentive spirometer. Encourage deep-breathing exercises. Check for pain.
Gastrointestinal	Encourage the client to increase fiber in their diet. Promote intake of oral fluids. Apply barrier ointment after bowel movements.

A. Laboratory results Lab results are diagnostic data, not part of the health history. They are obtained separately through testing.
B. Physical examination findings The physical exam is a separate component of the assessment and is not included in the health history, which focuses on subjective data.
C. Health habits The health history includes subjective data provided by the client, such as dietary habits, exercise routine, smoking, alcohol use, sleep patterns, and medication use. This information helps the nurse understand the client’s lifestyle and risk factors.
D. Observed client behaviors While a nurse may take note of behaviors, the health history is based on the client’s self-reported information, not observations.

Cardiopulmonary:

Encourage deep-breathing exercises.
Check for pain.

Rationale:

Encouraging deep-breathing exercises helps improve oxygenation and prevent complications such as atelectasis, especially since the client's oxygen saturation initially dropped but improved with deep breathing.

Checking for pain is essential as the client has been prescribed PRN morphine for pain management.

"Inform client to achieve two to four breaths per session when using an incentive spirometer" is not selected because while incentive spirometer use is encouraged, the prescribed plan instructs use every hour while awake rather than focusing on a specific number of breaths per session.

Gastrointestinal:

Promote intake of oral fluids.
Apply barrier ointment after bowel movements.

Rationale:

Promoting oral fluid intake helps prevent dehydration and supports bowel function, especially since the client reports multiple loose stools and nausea/vomiting.

Applying barrier ointment after bowel movements helps protect the skin from irritation and breakdown due to frequent loose stools.

"Encourage the client to increase fiber in their diet" is not selected because fiber intake is usually increased for constipation, whereas in this case, the client has diarrhea, and fiber could worsen symptoms.