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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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","C","D"]

Explanation

A. Contact precautions are essential to prevent the spread of MRSA to other patients and healthcare workers. This includes wearing gloves and gowns when entering the patient's room.

B. A low bacteria diet is not specifically relevant to managing MRSA and is more applicable to neutropenic patients.
C. Monitoring the white blood cell count helps in assessing the client's response to infection and identifying any potential systemic involvement.
D. Sending wound drainage for culture and sensitivity is crucial for identifying the specific strain of MRSA and determining the most effective antibiotic treatment.
E. Standard precautions are always necessary, but a mask is not required unless there is a risk of splashing or the patient has a respiratory infection.

A. incision dressing is dry and intact, and no bleeding is noted B. The client tolerated clear liquids post recovery and has advanced to a soft diet C. The client ambulated around the unit this morning and tolerated activity well D. Bowel sounds are present in all 4 quadrants, and per client report, she has passed flatus E. Pain is tolerated with analgesia PO

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

Explanation

The incision dressing is dry and intact, with no bleeding noted: This indicates that the surgical site is healing well without any signs of infection or complications. A dry and intact dressing suggests that there is no active bleeding or wound drainage, which is a positive sign of wound healing.

The client has tolerated clear liquids post-recovery and has advanced to a soft diet: Progression from clear liquids to a soft diet indicates that the client's gastrointestinal function is returning to normal. This progression suggests that there are no immediate concerns regarding postoperative nausea, vomiting, or bowel obstruction.

The client has ambulated around the unit and tolerated activity well: Ambulation and tolerance of activity demonstrate the client's physical mobility and overall strength. Being able to move around the unit without difficulty suggests that the client is recovering well from the surgical procedure and is regaining strength and function.

Bowel sounds are present in all 4 quadrants, and the client has passed flatus: The presence of bowel sounds in all four quadrants indicates normal gastrointestinal motility and function. Passing flatus is another positive sign of gastrointestinal recovery, suggesting that the client's bowels are active and functioning properly post-surgery.

Pain is tolerated with analgesia orally: The client's ability to tolerate pain with oral analgesia indicates effective pain management and suggests that the surgical incision site is not causing significant discomfort or distress. Effective pain control is essential for postoperative comfort and can facilitate the client's recovery process.

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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

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.

Correct Answer is ["A","C","D"]

Explanation

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

Explanation

Patient Data Exhibits The healthcare provider has obtained the arterial blood gas and chest X-ray results. New prescriptions have been entered in the client's electronic health record. Nursing Action: Indicated/ Contraindicated

A client experiencing an acute dystonic reaction presents with a laryngeal spasm. Which treatment should the nurse prepare?

A nurse is teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client's motivation to learn?

The nurse is planning care for a client with chronic kidney disease who is a resident at a long-term nursing facility. The client is anuric and has hemodialysis 3 times a week. Which intervention should the nurse include in the client's plan of care?

A client is admitted for medical management of a bowel obstruction. The drainage volume from the nasogastric tube over the last 12 hours is 300 milliliters. Which assessment finding provides the earliest indication that the client is experiencing gastrointestinal motility?

An older adult client presents to the emergency department with abdominal pain due to constipation. The nurse is providing a list of high-fiber foods to the client that the healthcare provider has recommended. Which action should the nurse implement when reviewing the list of foods?

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

Exhibits The nurse is caring for the client. Which of the following assessment findings should the nurse prioritize?

Patient Data

Exhibits

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