On the second postoperative day, a client who had a colon resection is starting to eat and ambulate with assistance. Although the client has a prescription for an oral analgesic, they request that the PCA containing morphine be continued for one more day due to fear of pain. Which intervention is most important for the nurse to implement?

Measure urinary output to ensure renal functioning.

Administer the oral analgesic medication an hour before discontinuing the PCA pump.

Monitor for a depressed respiratory rate.

Teach about the need to progress to a high-fiber diet.

Answer and Explanation

The Correct Answer is B

Choice A reason: Measuring urinary output is important for monitoring renal function, especially when using medications like morphine, but it is not the most critical intervention in this context.

Choice B reason: Administering the oral analgesic before discontinuing the PCA allows for the medication to take effect, preventing breakthrough pain and addressing the client's fear of pain.

Choice C reason: Monitoring for a depressed respiratory rate is crucial when a patient is on morphine, but the priority is to manage pain effectively as the client transitions to oral analgesics.

Choice D reason: Education on dietary needs is important for long-term recovery, but immediate pain management is a higher priority in the postoperative period.

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Free Nursing Study Resources

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

Explanation

Choice A reason: Sloughing tissue around wound edges may require debridement but does not typically require immediate intervention unless there is a significant change in the wound's condition.

Choice B reason: Loss of sensation could indicate nerve damage or developing compartment syndrome, which is a medical emergency requiring immediate intervention to prevent permanent damage.

Choice C reason: Weeping serosanguineous fluid is expected in burn wounds and does not necessarily require immediate intervention unless there is a significant increase in output or other signs of infection.

Choice D reason: Increased pain and pressure are signs of potential compartment syndrome or infection, both of which require prompt assessment and possible intervention.

Choice E reason: A change in the quality of peripheral pulses may indicate vascular compromise, which requires immediate intervention to restore circulation and prevent tissue death.

A. Teach the client to use an incentive spirometer every 2 hours while awake. B. Administer low molecular weight heparin as prescribed. C. Assess the pain level and medicate as needed, as prescribed. D. Maintain sequential compression devices while in bed. E. Remove the urinary catheter as soon as possible and encourage voiding.

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

Explanation

The correct answer is: A. Teach the client to use an incentive spirometer every 2 hours while awake and E. Remove the urinary catheter as soon as possible and encourage voiding.

Choice A reason:

Teaching the client to use an incentive spirometer every 2 hours while awake helps prevent postoperative pulmonary complications such as pneumonia. This intervention promotes lung expansion and clears secretions, reducing the risk of infection.

Choice B reason:

Administering low molecular weight heparin as prescribed is important for preventing deep vein thrombosis (DVT) and pulmonary embolism, but it does not directly reduce the risk of infection.

Choice C reason:

Assessing the pain level and medicating as needed is crucial for patient comfort and mobility, but it does not directly address infection prevention. Effective pain management can indirectly support recovery by enabling better mobility and respiratory function.

Choice D reason:

Maintaining sequential compression devices while in bed is aimed at preventing DVT, not infections. These devices help improve blood circulation and reduce the risk of blood clots.

Choice E reason:

Removing the urinary catheter as soon as possible and encouraging voiding reduces the risk of catheter-associated urinary tract infections (CAUTIs). Prompt removal of the catheter minimizes the duration of exposure to potential pathogens, thereby reducing infection risk.

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Naxlex Comprehensive Predictor Exams

When caring for a client with full-thickness burns to both lower extremities, which assessment findings warrant immediate intervention by the nurse? Select all that apply.

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

Explanation

An older adult client is admitted for the repair of a broken hip. To reduce the risk of infection in the postoperative period, which nursing care interventions should the nurse include in the client's plan of care? Select all that apply.

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

Explanation

A nurse is caring for a client who reports having run out of aspirin a week ago and has been taking ibuprofen as a substitute. Which information should the nurse obtain from the client first?

A client with bladder cancer had surgical placement of a ureter ileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately?

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The nurse is teaching a client with early osteoporosis the importance of including vitamin D with calcium supplements. Which information is most important for the nurse to provide to encourage the client's compliance in the management of progressing osteoporosis?

A client tells the nurse of concerns about possibly having a stomach ulcer because the client is experiencing heartburn and a dull gnawing pain that is relieved by eating. Which is the best response by the nurse?

A 22-year-old client is admitted to the hospital in diabetic ketoacidosis (DKA). The client's parent is insisting on knowing the laboratory test results. Which is the best response for the nurse to provide?