Exhibits

After the obstetrician leaves, the client appears confused and asks the nurse, "How will I know if I have high blood sugar?"
Which are the nurse's best responses? Select all that apply.

A. Have the client sign consent forms for procedures already performed: It is inappropriate to have the client sign consent forms for procedures that have already been completed. Consent must be obtained before procedures, and once a patient is awake, a retrospective consent is not legally valid.

B. Decrease the noise and light stimuli in the room as much as possible: As the client becomes more aware, it’s important to create a calm and quiet environment to reduce sensory overload. This helps the client adjust to the waking process and minimizes confusion or distress.

C. Consider extubating the client: Extubation should not be considered until the client is fully awake, alert, and able to maintain their own airway. The client is still recovering from the effects of anesthesia and requires ongoing monitoring before extubation can be safely considered.

D. Increase the propofol infusion: There is no indication that the propofol infusion needs to be increased, especially now that the client is waking up. The goal is to reduce sedation as the client becomes more aware, not increase it.

E. Determine the client's decision-making ability: As the client regains awareness, it’s crucial to assess her ability to make decisions. This will help guide the plan of care, particularly if she needs to provide consent for further procedures or treatment.

F. Explain all procedures: It’s important to explain any procedures and provide information about her care. This helps reduce anxiety, ensures the client understands what is happening, and promotes collaboration in the care process.

G. Notify the social worker the client is awake: The social worker should be notified as the client becomes more aware so they can assist with family contact and provide necessary emotional support.

H. Assess the client's pain: Assessing pain levels is crucial, especially given the trauma and the potential for post-operative discomfort. Ensuring pain is managed effectively will promote recovery and improve the patient's comfort.

A. Client exhibits a frequent productive cough: While a productive cough may indicate airway clearance, it does not assess the effectiveness of the incentive spirometer. The primary goal of the incentive spirometer is to improve lung expansion, not to stimulate coughing.

B. Client reports using the incentive spirometer every hour while awake: Regular use of the incentive spirometer is important, but it alone does not fully evaluate its effectiveness. The goal is to improve lung function, and a physical assessment is needed to gauge this.

C. Client's breath sounds are clear to auscultation bilaterally: This is the best indicator of the effectiveness of the incentive spirometer. Clear breath sounds suggest improved lung expansion and ventilation, which is the primary goal of using the device.

D. Client demonstrates proper use of an incentive spirometer: While proper technique is essential for effectiveness, demonstrating correct use does not fully assess whether the desired outcomes are achieved.