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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Loss of bone mineral density occurs in osteoporosis, not osteoarthritis.
B. An infectious process in synovial fluid suggests septic arthritis, not osteoarthritis.
C. Osteoarthritis is caused by wear-and-tear destruction of joint cartilage, leading to pain and stiffness.
D. A systemic inflammatory response is characteristic of rheumatoid arthritis, not osteoarthritis.
Correct Answer is D
Explanation
A. Yellow expectorated sputum. This is typical in pneumonia, indicating bacterial infection, but it does not require immediate intervention compared to wheezing.
B. Shortness of breath on exertion. This is common in COPD and pneumonia, but the wheezing represents a more urgent concern for respiratory compromise.
C. Oral temperature of 100.5°F (38.1°C). This is a mild fever, which is common in infections like pneumonia, but it does not warrant immediate intervention like wheezing does.
D. Bilateral diffuse wheezing. Wheezing suggests bronchospasm, which could indicate airway obstruction or respiratory distress. This requires immediate attention, especially in a client with COPD and pneumonia, both of which can compromise respiratory function.
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