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Exhibits

Click to select the 5 most important nursing interventions for postoperative client care.

Encourage sitting up and ambulation

Monitor for bleeding once daily

Use incentive spirometer every 1 hour

Promote adequate hydration

Assess for sedation after pain medications

Complete neurologic assessment every 2 hours

Administer pain medication after activity

Answer and Explanation

Correct Answer : A,C,D,E,G

A.   Encouraging the client to sit up and ambulate helps prevent complications such as atelectasis and deep vein thrombosis by promoting lung expansion and blood circulation.
B.   While monitoring for bleeding is important, in most stable postoperative cases, continuous monitoring isn't necessary. Once daily checks are often sufficient.
C.   Regular use of the incentive spirometer helps prevent respiratory complications such as pneumonia by promoting deep breathing and lung expansion.
D.   Adequate hydration is essential for wound healing, preventing urinary retention, and maintaining overall physiological function. Encourage the client to drink fluids within their prescribed limits.
E.   Monitoring for sedation after administering pain medications is crucial to ensure the client's safety and prevent respiratory depression. Assess the client's level of consciousness, respiratory rate, and oxygen saturation regularly.
F.   Neurological assessments are usually not required this frequently unless there are specific concerns.
G.   Administering pain medication after activity helps manage postoperative pain effectively, enabling the client to participate in necessary activities such as ambulation and respiratory exercises. It's important to ensure that pain is adequately controlled to facilitate recovery and promote comfort.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. Serum electrolytes are important to monitor in chronic kidney disease but do not directly relate to the effects of epoetin alfa.

B. Platelet count is not typically affected by epoetin alfa and does not directly address the client’s symptoms of tiredness.
C. Complete blood count (CBC) is crucial to monitor, especially hemoglobin and hematocrit levels, as epoetin alfa is used to treat anemia in chronic kidney disease, which can cause fatigue.
D. Liver enzymes are not directly related to the effects of epoetin alfa and the symptoms described.

A. Bends from the waist to pick trash off the floor. B. Leans forward to pull a pan from a high shelf. C. Locks knees while preparing food on the counter. D. Widens stance while working near the sink. E. Brings a heavy can close to body before lifting.

Correct Answer is ["D","E"]

Explanation

A. Bending from the waist to pick up trash can cause imbalance and strain; it is safer to bend at the knees.

B. Leaning forward to pull a pan from a high shelf can lead to loss of balance; using a step stool is safer.
C. Locking the knees can lead to loss of balance and is not a recommended posture.

D. Widening the stance provides a stable base and helps maintain balance while working.
E. Bringing a heavy can close to the body before lifting uses proper body mechanics, reducing the risk of strain and promoting balance.

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Exhibits Click to select the 5 most important nursing interventions for postoperative client care.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with chronic kidney disease reports to the nurse of feeling increasingly tired. The client receives injections for epoetin alfa three times a week. Which laboratory value should the nurse review?

Correct Answer is C

Explanation

The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. What behavior(s) indicate the client understands how to maintain balance safely? Select all that apply.

Correct Answer is ["D","E"]

Explanation

Patient Data Exhibits Each row and each column must have at least one, but may have more than one, response option selected. Intervention: Promotes safety/ Does not promote safety

A client with unilateral hearing loss is admitted for a scheduled surgery. Which technique should the nurse use to provide education about pain relief options?

Which instruction should the nurse delegate to an unlicensed assistive personnel (UAP)?

The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?

Following a fractured left tibia, which necessitated placement of long leg cast, a client is using crutches to ambulate. During an orthopedic follow-up visit, a client reports to the nurse having difficulty managing the crutches. Which assessment should the nurse perform?

The healthcare provider prescribes 1 unit (350 mL) of packed red blood cells (PRBC) to infuse over 4 hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter the numeric value only. Round to the nearest whole number.)

A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose?

Exhibits

Click to select the 5 most important nursing interventions for postoperative client care.