The nurse is caring for an older adult client who is admitted to the surgical unit following a partial gastrectomy. In addition to frequent position changes, which postoperative intervention is most beneficial for the nurse to perform in preventing respiratory complications?

Promote full diaphragmatic excursion by massaging the back.

Note areas of atelectasis on the daily chest x-rays.

Assist to a chair the day after surgery when the condition is stable.

Provide ice or oral liquids when the client passes flatus.

Answer and Explanation

The Correct Answer is A

A.   Promoting full diaphragmatic excursion by massaging the back helps to facilitate deep breathing and lung expansion, which is essential for preventing respiratory complications such as atelectasis and pneumonia after surgery.
B.   Noting areas of atelectasis on daily chest x-rays is important for assessing respiratory status, but it is a monitoring intervention rather than a preventive intervention.
C.   Assisting the client to a chair the day after surgery when the condition is stable promotes early mobility and prevents complications such as deep vein thrombosis, but it may not directly
address respiratory complications.
D.   Providing ice or oral liquids when the client passes flatus may be part of the postoperative care plan, but it does not directly address respiratory complications. It's more related to bowel function and hydration status.

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Correct Answer is C

Explanation

A. Encouraging the client to participate in group activities may be beneficial but may not address the immediate need for increased communication and engagement.
B. Scheduling a daily conference with the social worker may provide support but may not directly address the client's withdrawal and noncommunicative behavior.
C. Engaging the client in non-threatening conversations is important to assess the client's current emotional state, understand the reasons for withdrawal, and provide support and encouragement for communication and interaction.
D. Encouraging the client's family to visit more often may be helpful for social support, but it may not address the underlying issue of the client's withdrawal and noncommunicative behavior.

A. Administer aspirin to prevent further clot formation and platelet clumping. B. Initiate bilateral intermittent sequential pneumatic compression devices. C. Place an indwelling urinary catheter and measure strict intake and output. D. Notify the stroke team to assist with acute assessment and management.

Correct Answer is D

Explanation

A. Administering aspirin may be appropriate for suspected ischemic stroke; however, it should not be done without confirmation of diagnosis and evaluation by the stroke team.
B. Initiating pneumatic compression devices is not the priority in this situation. Acute assessment and management of the suspected stroke take precedence.
C. Placing an indwelling urinary catheter and measuring strict intake and output may be necessary for ongoing care but is not the priority when the client is presenting with symptoms suggestive of a stroke.
D. Notifying the stroke team to assist with acute assessment and management is the priority intervention. Time is crucial in the management of stroke, and early intervention can help minimize neurological damage and improve outcomes.

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The nurse is caring for an older adult client who is admitted to the surgical unit following a partial gastrectomy. In addition to frequent position changes, which postoperative intervention is most beneficial for the nurse to perform in preventing respiratory complications?

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Naxlex Comprehensive Predictor Exams

The nurse notes that a client with depression has been more withdrawn and noncommunicative during the past two weeks. Which Intervention is most important to include in the updated plan of care for this client?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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