To promote effective coughing, deep breathing, and ambulation in the postoperative client, what nursing action is most important?

Provide adequate and regular pain medication

Teach the client pursed-lip breathing

Encourage continued bedrest and ensure quality sleep

Use an incentive spirometer to motivate the client

Answer and Explanation

The Correct Answer is A

A. Provide adequate and regular pain medication: Effective pain management is crucial for postoperative clients to perform deep breathing, coughing, and ambulation comfortably and effectively. Pain relief enables better participation in these activities.
B. Teach the client pursed-lip breathing: While pursed-lip breathing is beneficial for some respiratory conditions, it is less directly related to promoting postoperative activities compared to pain management.
C. Encourage continued bedrest and ensure quality sleep: Encouraging bedrest may hinder postoperative recovery; instead, ambulation and movement are important for recovery.
D. Use an incentive spirometer to motivate the client: Although an incentive spirometer helps with deep breathing, it is less effective without proper pain management to support these activities.

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Correct Answer is A

Explanation

A. Warfarin (Coumadin): This is the correct choice. Warfarin is an anticoagulant that increases the risk of bleeding during and after surgery. The surgeon needs to be notified to consider holding the medication and to adjust the surgical plan if necessary.
B. Gabapentin (Neurontin): While important for pain management, it does not significantly impact surgical procedures or bleeding risk.
C. Xanax (Alprazolam): This medication is a benzodiazepine used for anxiety, which might be relevant for preoperative anxiety but does not require immediate notification of the surgeon.
D. Atenolol (Tenormin): This beta-blocker is used for hypertension and heart conditions but does not require immediate notification of the surgeon unless there are specific cardiac concerns related to surgery.

A. The 22-year-old client who does not understand English B. The 17-year-old client who has two fractured wrists C. The 65-year-old client who cannot read or write D. The 80-year-old client who is not oriented to the day

Correct Answer is D

Explanation

A. The 22-year-old client who does not understand English: This client can still consent legally if provided with a translator or interpreter to ensure understanding.
B. The 17-year-old client who has two fractured wrists: This client is a minor and would typically need a legal guardian to consent, but their ability to consent is not the primary issue here.
C. The 65-year-old client who cannot read or write: Literacy issues do not necessarily preclude the ability to understand and consent, especially if the consent process is explained to them.
D. The 80-year-old client who is not oriented to the day: This client lacks orientation and thus may not be able to fully understand or make an informed decision about the surgery, affecting their ability to consent legally.

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To promote effective coughing, deep breathing, and ambulation in the postoperative client, what nursing action is most important?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is taking a medication history of a client scheduled for surgery the next morning. Which medication requires the nurse to immediately notify the surgeon?

Correct Answer is A

Explanation

The nurse is asked to witness surgical consent forms were obtained for clients, in the preoperative holding area. What client would not be able to consent legally to surgery?

Correct Answer is D

Explanation

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