A postoperative client returns to the nursing unit following a ureterolithotomy via a flank incision. Which potential problem has the highest priority when planning nursing care for this client?

Activity intolerance.

Fluid volume excess.

Ineffective airway clearance.

Altered nutrition; less than body requirements.

Answer and Explanation

The Correct Answer is C

Choice A reason: Activity intolerance is important but not the highest priority immediately after surgery.

Choice B reason: Fluid volume excess can be a concern but is not as critical as ensuring effective airway clearance.

Choice C reason: Ineffective airway clearance is the highest priority as it directly impacts the client’s ability to breathe and maintain adequate oxygenation, which is crucial for postoperative recovery.

Choice D reason: Altered nutrition is also important but is not the immediate priority compared to airway clearance.

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Correct Answer is A

Explanation

Choice A reason: Completing ongoing focused assessments, particularly for a client with wrist restraints, requires the clinical judgment and skills of an RN.

Choice B reason: Supervising a newly hired graduate nurse is important but can also be done by the charge nurse or another experienced RN.

Choice C reason: Transporting a client to the radiology department can be done by a UAP or PN.

Choice D reason: Administering PRN oral analgesics can be delegated to a PN.

A. Prepare client for endotracheal intubation. B. Apply a nonrebreather mask at 100% oxygen. C. Place the client in a forward-leaning position. D. Obtain a sputum sample for culture and sensitivity.

Correct Answer is C

Explanation

Choice A reason: Intubation is not the first step in managing COPD exacerbation unless the client is in severe respiratory failure (e.g., unresponsive, unable to protect airway, pH severely low). This client is alert, able to maintain vitals, so less invasive interventions should be tried first.

Choice B reason: High-flow oxygen at 100% can eliminate the hypoxic drive to breathe in COPD patients, leading to CO₂ retention and respiratory acidosis. Controlled oxygen therapy (e.g., nasal cannula or Venturi mask at 1–2 L/min or FiO₂ 24–28%) is preferred.

Choice C reason: This "tripod" position reduces work of breathing by optimizing diaphragmatic expansion and helping accessory muscles function more effectively. It is an evidence-based immediate nursing intervention for acute dyspnea in COPD.

Choice D reason: Obtaining a sputum sample for culture and sensitivity is important for identifying the cause of the infection but is not the immediate priority.

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A postoperative client returns to the nursing unit following a ureterolithotomy via a flank incision. Which potential problem has the highest priority when planning nursing care for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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