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.
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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Related Questions
Correct Answer is B
Explanation
A. Client's healthcare power of attorney: While important, this information may not be
immediately relevant to the client's current condition and the reason for contacting the healthcare provider.
B. Increasing confusion of the client: This information indicates a change in the client's status and is the most pertinent to the client's current condition, warranting immediate attention.
C. Fall at home as reason for admission: While important for background information, the reason for admission is already known, and the focus of the communication should be on the client's current status.
D. Currently prescribed medications: This information is important but may not be the priority when reporting a change in the client's condition.
Correct Answer is D
Explanation
A. Matching ID bands of all infants and mothers on the unit is an important step in ensuring infant safety and preventing mix-ups. However, this action does not address the immediate need to secure the facility and prevent the potential abduction of the newborn.
B. Determining if the newborn is in the nursery is important, but it is not the first priority. The nurse must act immediately to secure the unit and prevent the possibility of the infant being removed from the hospital.
C. Asking the mother if any visitors were expected may provide helpful information, but it is not the first action. The priority is to ensure the safety of all infants and prevent unauthorized exits from the facility.
D. Activating the lockdown procedure is the first and most critical action. This ensures that all exits are secured, preventing the potential abductor from leaving the facility. Once the lockdown is in place, the nurse can proceed with further actions to locate the infant and investigate the situation.
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