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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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. An ionized calcium level significantly above the reference range can lead to cardiac dysrhythmias and requires immediate attention to assess cardiac function.
B. While urine output and characteristics are important indicators of renal function, cardiac assessment takes priority due to the potential cardiac effects of hypercalcemia.
C. Assessment of deep tendon reflexes is relevant since hypercalcemia can lead to muscle weakness and diminished reflexes. However, this should be done after assessing for any cardiac dysrhythmias.
D. Comparing muscle strength bilaterally is important for assessing neurological integrity but is not the priority when hypercalcemia is suspected.

A. Regression. B. Suppression. C. Compensation. D. Sublimation.

Correct Answer is D

Explanation

A. Regression involves reverting to behaviors from an earlier developmental stage, which is not demonstrated in this scenario.
B. Suppression is the conscious decision to delay paying attention to a thought or feeling, which is not evident here.
C. Compensation involves making up for a perceived deficiency by emphasizing another trait or skill, which does not apply to this situation.
D. Sublimation is the process of channeling unacceptable impulses into socially acceptable activities. By vigorously working on the leather belt, the client is redirecting potentially aggressive energy into a constructive and creative outlet.

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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

When assessing a client with an ionized calcium level of 17 mg/dL (4.25 mmol/L), which intervention is most important for the nurse to implement? Reference Range lonized Calcium [Adult 4.6 to 5.1 mg/dL (1.15 to 1.35 mmol/L)]

Correct Answer is A

Explanation

A client who is participating in an anger management assignment asks to make a leather belt in occupational therapy. The client begins pounding the leather vigorously with a mallet to imprint designs on the belt. Which defense mechanism is the client using?

Correct Answer is D

Explanation

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

Patient Data Exhibits Which assessment findings indicate that the client has stabilized? Select all that apply.

The nurse is assessing the feet of a client with type 1 diabetes mellitus. Which finding requires immediate intervention by the nurse?

The nurse implements a secondary prevention program for sexually transmitted infections in a local health center. Which outcome indicates that the program was effective?

The practical nurse (PN) believes that a prescription for a child is incorrect because the dosage prescribed is the usual adult dosage. Which action should the PN take?

The charge nurse observes a new nurse preparing to irrigate an intravenous catheter. The new nurse is attaching an 18-gauge needle. Which action should the charge nurse take?

The adult child of an older adult client who has Parkinson's disease, calls the clinic and reports that the client has been confused for the past week. What action(s) should the nurse take? Select all that apply.

A client's telemetry monitor indicates ventricular fibrillation (VF). Which action should the nurse implement immediately?

Patient Data

Exhibits

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