The nurse is caring for an immobile client after spinal surgery. Which action is most important for the nurse to take to prevent postoperative complications?

Progress diet slowly from ice chips to clear liquids.

Maintain intervascular infusion rate.

Apply intermittent pneumatic compression devices.

Obtain frequent pain level assessments.

Answer and Explanation

The Correct Answer is C

A.   Progressing the diet is important but does not address immobility-related complications.
B.   Maintaining the IV infusion rate is necessary but not specific to preventing complications from immobility.
C.   Applying intermittent pneumatic compression devices helps prevent deep vein thrombosis (DVT), a significant risk for immobile clients post-surgery. This is a critical preventative measure for immobility-related complications.
D.   Frequent pain assessments are important but do not specifically prevent complications from immobility.

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Correct Answer is B

Explanation

A. This is an open-ended question, not closed-ended.

B. A closed-ended question like "Does your pain occur when walking short distances?" is specific and allows the nurse to understand the triggers and pattern of the pain, which is important for assessing unstable angina.
C. "When did you first notice the pain in your chest?" is also a relevant question but less specific to understanding the current pattern and triggers of the pain.
D. "How do you feel when the pain becomes noticeable?" is open-ended and less specific in identifying triggers and patterns of the pain.

A. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity. B. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds. C. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid. D. The client with an obstruction of the large intestine who is experiencing abdominal distention.

Correct Answer is A

Explanation

A. Abdominal rigidity in a client with a bowel obstruction due to a volvulus indicates possible peritonitis, which is a medical emergency.
B. Paralytic ileus with absent bowel sounds is concerning but not immediately life- threatening.
C. A nasogastric tube draining greenish fluid is expected in small bowel obstruction.

D. Abdominal distention in large intestine obstruction is concerning but less urgent than potential peritonitis.

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The nurse is caring for an immobile client after spinal surgery. Which action is most important for the nurse to take to prevent postoperative complications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While completing an admission assessment for a client with unstable angina, which closed ended questions should the nurse ask about the client's chest pain?

Correct Answer is B

Explanation

After receiving report on an inpatient acute care unit, which client should the nurse assess first?

Correct Answer is A

Explanation

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