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 D

Explanation

A. Gonorrhea: While sexually transmitted infections can affect pregnancy, the symptoms described are not consistent with gonorrhea.
B. Group B Streptococcus: Group B Streptococcus is commonly screened for in pregnant individuals but does not typically present with the described symptoms.
C. Toxoplasmosis: Toxoplasmosis can affect pregnancy, but the symptoms described are not specific to toxoplasmosis.
D. Rubella: Rubella infection during pregnancy can lead to congenital rubella syndrome, which can cause birth defects. The symptoms described are consistent with rubella infection.

A. "I am happy that you are getting better and will be able to go home." B. "Tomorrow I will talk to that nurse about how you were treated last night." C. "I am glad you like me. Which nurse was acting aloof to you?" D. "What did the night nurse do that makes you think the nurse is aloof?"

Correct Answer is A

Explanation

A. "I am happy that you are getting better and will be able to go home."
This response focuses on the client’s progress and avoids engaging with their polarized views. It provides positive reinforcement and shifts the focus toward recovery.

B. "Tomorrow I will talk to that nurse about how you were treated last night."
This could escalate the situation and may inadvertently validate the client's idealization or devaluation of others, without fully understanding the dynamics.

C. "I am glad you like me. Which nurse was acting aloof to you?"
This response reinforces the client’s idealization of the current nurse, which could perpetuate dichotomous thinking.

D. "What did the night nurse do that makes you think the nurse is aloof?"
This invites the client to focus on negative perceptions of the night nurse, potentially escalating their emotional instability.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client at 10-weeks gestation reports a maculopapular rash on the face, fever, malaise, sore throat, and lymphadenopathy. Which laboratory result should the nurse review?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

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