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Patient Data

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.   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.   Pain medications should be administered prophylactically before activity. However, it can also be administered after activity in case the client complains of pain.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. Monitoring incision drainage is important for infection and wound healing but not directly related to the effectiveness of compression devices.
B. Observing both lower extremities for redness and swelling directly assesses the effectiveness of the pneumatic compression devices in preventing deep vein thrombosis (DVT).
C. Evaluating the use of an incentive spirometer is important for respiratory function but unrelated to the compression devices.
D. Palpating peripheral pulse points is useful for circulation assessment but does not specifically evaluate the prevention of DVT, which is the primary purpose of the compression devices.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

Uremic Encephalopathy: The client has chronic kidney disease and elevated blood urea nitrogen (BUN) levels, indicating impaired kidney function. Symptoms such as feeling tired, fever, and possibly altered mental status can be associated with uremic encephalopathy, a condition that arises from the accumulation of toxins in the blood due to kidney failure.

Fluid Volume Overload: The client has elevated blood pressure (140/86 mm Hg), an irregular and elevated heart rate (117 beats/minute), and respiratory rate (36 breaths/minute), which can be signs of fluid volume overload. Additionally, the slight bibasilar infiltrates observed in the chest X-ray suggest potential fluid accumulation in the lungs.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?

Correct Answer is B

Explanation

Patient Data Exhibits After completing the initial assessment, the nurse has reviewed the 0930 laboratory results of blood specimens obtained in the outpatient clinic. Drag from Word Choices to complete the sentence. The nurse determines that the findings are reflective of and

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). What nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

After falling down the basement steps, a client is brought to the emergency department. X-ray results confirm that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?

A client with an acute myocardial infarction (MI) is given a thrombolytic medication, aspirin, and IV heparin in the emergency department. Which finding indicates the client is having a satisfactory response?

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

The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first?

The nurse is caring for a client with pneumonia who now develops initial signs of septic shock and multi-organ failure. The healthcare provider prescribes a sepsis protocol. Which intervention is most important for the nurse to include in the plan of care?

Patient Data

Exhibits

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