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. While fever after vaccination should be monitored, not all fevers after vaccination are serious.
Low-grade fevers are common and may not require immediate reporting unless they are persistent or accompanied by other concerning symptoms.
B. Children's aspirin should not be given to prevent inflammation after vaccination due to the risk of Reye's syndrome. Acetaminophen or ibuprofen may be recommended for fever or discomfort after vaccination, but not aspirin.
C. Applying a cool pack to the injection site can help reduce discomfort and swelling, which are common reactions to vaccines. This is an appropriate instruction for caring for the injection site after receiving the Hib vaccine.
D. Keeping the child home from daycare for the next two days is not necessary unless the child experiences unusual symptoms or reactions to the vaccine. Most children can resume normal activities after vaccination.

A. Toxoplasmosis. B. Group B Streptococcus. C. Gonorrhea. D. Rubella.

Correct Answer is D

Explanation

A. Toxoplasmosis: While toxoplasmosis can cause symptoms similar to those described, it is not typically associated with a maculopapular rash on the face. Moreover, routine screening for toxoplasmosis is not typically performed during pregnancy unless indicated by specific risk factors.
B. Group B Streptococcus: Group B Streptococcus is primarily associated with maternal
colonization and neonatal infection, but it does not typically present with a maculopapular rash on the face in the mother.
C. Gonorrhea: Gonorrhea can cause systemic symptoms, but it is not commonly associated with a maculopapular rash on the face. Additionally, routine screening for gonorrhea during pregnancy typically focuses on genital sites rather than systemic symptoms.

D. Rubella: Rubella, or German measles, presents with a maculopapular rash on the face (often described as a "slapped cheek" appearance) along with fever, malaise, sore throat, and
lymphadenopathy. Rubella infection during pregnancy can lead to congenital rubella syndrome, which can have serious consequences for the developing fetus. Therefore, it is important to
review rubella immunity status in pregnant women presenting with these symptoms.

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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

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