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 ["A","D","E"]

Explanation

A. Loss of sensation to the left lower extremity warrants immediate intervention as it may indicate nerve damage, impaired circulation, or compartment syndrome. These findings require urgent evaluation to prevent permanent damage.

B. Sloughing tissue around wound edges is a common finding in burn injuries during the healing process. While it requires monitoring and proper wound care, it does not necessitate immediate intervention unless accompanied by signs of infection.

C. Weeping serosanguineous fluid from wounds is expected in burn injuries, especially in the early stages of healing. This finding does not indicate an acute complication.

D. Reporting increased pain and pressure is a critical finding as it may indicate compartment syndrome, a condition where increased pressure within a muscle compartment impairs circulation and tissue viability. Immediate intervention is required to prevent further complications.

E. A change in the quality of peripheral pulses is an alarming finding as it suggests impaired circulation, potentially due to edema, vascular compromise, or compartment syndrome. This requires prompt assessment and action to restore adequate blood flow.

A. Encourage the use of ice on the areola. B. Recommend using a breast shield. C. Teach about the use of a breast pump. D. Offer supplemental formula feedings.

Correct Answer is B

Explanation

A. Encouraging the use of ice on the areola is not appropriate for addressing inverted nipples. Ice may cause discomfort and vasoconstriction, making latching more difficult.
B. Recommending the use of a breast shield can help draw out inverted nipples, making it easier for the baby to latch onto the breast. Breast shields can be used temporarily until the nipples
become more erect or until breastfeeding techniques are established.
C. Teaching about the use of a breast pump may be appropriate for establishing milk supply or relieving engorgement, but it does not directly address the issue of inverted nipples or difficulty with latching.
D. Offering supplemental formula feedings should be a last resort and should only be considered if other methods of addressing latch difficulties, such as using a breast shield or seeking
assistance from a lactation consultant, have been unsuccessful.

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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

When caring for a client with full-thickness burns to both lower extremities, what assessment finding(s) warrant immediate intervention by the nurse? Select all that apply.

Correct Answer is ["A","D","E"]

Explanation

A client who is one day postpartum tells the nurse that her baby cannot latch onto the breast. The nurse determines that the client's nipples are inverted. Which action should the nurse implement?

Correct Answer is B

Explanation

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