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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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Free Nursing Study Resources

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

Explanation

A. Changing the glucose monitoring device is unlikely to address the root cause of the elevated blood sugars.
B. Some asthma medications, such as corticosteroids, can increase blood glucose levels. Evaluating these medications is essential.
C. Incorrect technique in monitoring blood glucose can lead to inaccurate readings.

Having the client demonstrate the technique can identify any errors.

D. Ensuring that a new insulin needle is used for each administration is important to prevent infection and ensure proper dosage.

E. Understanding the client’s daily routine, including diet, exercise, and stress levels, can provide insight into factors affecting blood glucose control.

A. Ask the spouse if the client seems to be depressed. B. Tell the spouse to wait outside so the client can be assessed for depression. C. Explain that depression often occurs after a life-threatening experience. D. Encourage the client to further describe his feelings.

Correct Answer is D

Explanation

A. Asking the spouse about the client's depression can provide insights but might not be as effective as directly addressing the client.
B. While privacy is important, the spouse can often provide additional valuable information.
C. Explaining about post-MI depression is informative but does not directly assess the client's current emotional state.
D. Encouraging the client to describe his feelings allows the nurse to perform a thorough assessment of the client’s mental state and identify any signs of depression or anxiety.

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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

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

Explanation

Correct Answer is D

Explanation

A client is admitted for medical management of a bowel obstruction. The drainage volume from the nasogastric tube over the last 12 hours is 300 milliliters. Which assessment finding provides the earliest indication that the client is experiencing gastrointestinal motility?

The nurse observes an unlicensed assistive personnel (UAP) applying an alcohol-based hand rub while leaving a client's room after taking vital signs. Which action should the nurse take?

The nurse wants to teach the client about the long-term phase symptoms of rape-trauma syndrome. What symptoms are consistent with long-term rape trauma? Select all that apply.

During discharge teaching, an overweight client with heart failure (HF) is asked to make a grocery list for the nurse to review. What food choice(s) included on the client's list should the nurse encourage? Select all that apply.

A nurse is caring for an older adult client who has constipation. Which of the following actions should the nurse take?

What 2 orders should the nurse complete first?

A client who underwent cardiac stent placement four days ago arrives to the emergency department reporting a sudden onset of chest pressure and shortness of breath. Which action should the nurse take next?

Exhibits

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