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Exhibits

The nurse is caring for the client the morning after her surgery.

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. Early ambulation helps prevent complications such as atelectasis, pneumonia, and deep vein thrombosis (DVT). It also promotes intestinal motility.
B. Monitoring for bleeding should be more frequent, especially in the immediate postoperative period, rather than just once daily.
C. This helps prevent respiratory complications such as atelectasis and promotes lung expansion.
D. Adequate hydration is essential to maintain fluid balance, promote healing, and prevent complications such as urinary tract infections and constipation.
E. Monitoring for sedation is crucial to ensure that pain medications are not causing excessive drowsiness, which could impair the client's ability to participate in activities such as ambulation and use of the incentive spirometer.
F. While assessing neurological status is important, frequent neurological assessments are more relevant for clients with neurological conditions or concerns. In this case, routine assessments should be sufficient unless the client has specific neurological symptoms.
G. Administering pain medication after activity helps manage pain more effectively and encourages the client to engage in necessary postoperative activities.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Position bedside table so the client can lean across it. Clients with pancreatitis often find relief from pain by sitting up and leaning forward. This position helps alleviate the pressure on the pancreas and can reduce pain.

B. Raise head of bed to a 90-degree angle. Raising the bed too high may increase discomfort for clients with pancreatitis. The more comfortable position is typically sitting up but leaning forward.

C. Encourage rest until the analgesic becomes effective. While rest is important, positioning the client to alleviate pain should take priority in this situation.

D. Place bed in a reverse Trendelenburg position. This position is typically used for patients with cardiovascular or abdominal issues but is not the most effective for managing pancreatitis pain.

A. Bradykinesia. B. Stooped posture. C. Orthostatic hypotension. D. Shuffling, propulsive gait. E. Muscular rigidity.

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

Explanation

A. Bradykinesia (slowness of movement) is a hallmark symptom of Parkinson's disease and will directly affect the client's mobility, requiring intervention to assist with movement and prevent falls.

B. Stooped posture is common in Parkinson's disease and can contribute to impaired balance and increase the risk of falls, making interventions for posture and mobility necessary.

C. Orthostatic hypotension is not specifically a mobility issue, but it can affect the client's overall safety and risk for falls. It may require monitoring and interventions to address blood pressure changes, but it is not as directly related to mobility as the other symptoms.

D. Shuffling, propulsive gait is a typical motor symptom of Parkinson's disease and increases the risk of falls, necessitating planning for interventions to improve gait and balance.

E. Muscular rigidity is another classic symptom that can limit the client's mobility, causing difficulty with movement, and requires interventions to improve range of motion and reduce stiffness.

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Exhibits The nurse is caring for the client the morning after her surgery. Click to select the 5 most important nursing interventions for postoperative client care.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with pancreatitis reports severe epigastric pain, so the nurse administers a prescribed narcotic analgesic Ten minutes later, the client insists on sitting up and leaning forward. Which intervention should the nurse implement?

Correct Answer is A

Explanation

A client with Parkinson's disease (PD) is admitted to the medical surgical unit and the nurse assesses the client's mobility needs. Which finding(s) indicate the need to plan interventions related to the client's mobility? Select all that apply.

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

Explanation

During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care?

The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?

In caring for a client following a head injury, the nurse plans to assess for rhinorrhea so that a sample can be tested for the presence of cerebrospinal fluid (CSF). At which location should the nurse observe for this finding? (Click the chosen location. To change, click on the new location.)

A client with renal calculi is experiencing hematuria and reports severe flank pain. Which intervention should the nurse implement first?

After a scheduled downtime, the computer documentation system fails to restart. Which action should the nurse take first?

A client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant heart sounds, and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?

The nurse is teaching a female client about preventive measures for urinary tract infections (UTI). Which information should the nurse include?

Exhibits

The nurse is caring for the client the morning after her surgery.

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