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 ["B","C","D","E"]

Explanation

A. Explaining the purpose of a low bacteria diet is not directly relevant to the management of osteomyelitis or MRSA infection. This intervention would not be included in the plan of care.
B. Using standard precautions and wearing a mask is essential when caring for a client with an open draining wound, especially when MRSA infection is suspected. This helps prevent the spread of infection to healthcare workers and other clients.
C. Sending wound drainage for culture and sensitivity is important to identify the causative organism and determine the most effective antibiotic therapy.
D. Monitoring the client's white blood cell count is important for assessing the client's response to treatment and detecting any signs of worsening infection.
E. Instituting contact precautions for staff and visitors is necessary to prevent the transmission of MRSA to others. This includes wearing gowns and gloves when entering the client's room and ensuring proper hand hygiene practices are followed.

Correct Answer is []

Explanation

Cerebral edema is the most likely condition the client is experiencing based on the history of submersion, subsequent resuscitation, and the finding of brain edema noted on the head CT scan.

Implementing seizure precautions is essential because cerebral edema can increase the risk of seizures. Discontinuing the 0.9% sodium chloride solution IV infusion is necessary because hyponatremia (low serum sodium) is associated with cerebral edema, and reducing fluid intake can help manage cerebral edema.

Monitoring strict intake and output is crucial to assess the client's fluid balance and ensure that any changes in fluid status are promptly addressed. Monitoring neurologic status is vital for detecting any changes in consciousness, responsiveness, or neurological function, which could indicate worsening cerebral edema or neurological complications.

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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

A client with osteomyelitis from a compound fracture of the left tibia has an open draining wound and is admitted with possible methicillin-resistant Staphylococcus aureus (MRSA infection. What intervention(s) should the nurse include in the plan of care? Select all that apply.

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

Explanation

Patient data Exhibits Complete the diagram by dragging from the choices below to specify 1 potential condition the client is most likely experiencing, 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client's progress.

Correct Answer is []

Explanation

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