When entering the room of a sedated postoperative client, which assessment requires immediate intervention by the nurse?

Low intermittent suction prescribed for the nasogastric tube is turned off.

A Hemovac drain is partially full of serous drainage and is not compressed.

The urinary catheter drainage bag is almost completely full of amber urine.

Oxygen is being administered via nasal cannula at 4 L/minute without humidification.

Answer and Explanation

The Correct Answer is A

A. A nasogastric tube prescribed for low intermittent suction is intended to remove gastric contents and prevent accumulation of air and secretions. If the suction is turned off gastric contents can accumulate, risk of vomiting and aspiration increases, especially in a sedated client with a reduced gag reflex, abdominal distention and discomfort may occur, and postoperative complications can develop quickly. Because aspiration directly threatens airway and breathing, this finding requires immediate intervention.

B.   A Hemovac drain must be compressed to maintain negative pressure. If not compressed, drainage may not be effective, but this is not immediately life-threatening compared to airway/aspiration risk
C.   An almost completely full urinary catheter drainage bag requires attention but does not pose an immediate threat to the client's condition.
D.   Oxygen up to 4 L/min via nasal cannula typically does not require humidification in most clinical settings. May cause mild dryness but is not an immediate threat to airway or life.

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

Explanation

A. Early ambulation helps prevent complications such as atelectasis, pneumonia, and deep vein thrombosis (DVT). It also promotes intestinal motility.
B. Monitoring for bleeding should be more frequent, especially in the immediate postoperative period, rather than just once daily.
C. This helps prevent respiratory complications such as atelectasis and promotes lung expansion.
D. Adequate hydration is essential to maintain fluid balance, promote healing, and prevent complications such as urinary tract infections and constipation.
E. Monitoring for sedation is crucial to ensure that pain medications are not causing excessive drowsiness, which could impair the client's ability to participate in activities such as ambulation and use of the incentive spirometer.

F. While assessing neurological status is important, frequent neurological assessments are more relevant for clients with neurological conditions or concerns. In this case, routine assessments should be sufficient unless the client has specific neurological symptoms.
G. Pain medications should be administered prophylactically before activity. However, it can also be administered after activity in case the client complains of pain.

A. Ask the spouse if the client seems to be depressed. B. Tell the spouse to wait outside so the client can be assessed for depression. C. Explain that depression often occurs after a life-threatening experience. D. Encourage the client to further describe his feelings.

Correct Answer is D

Explanation

A. Asking the spouse about the client's depression can provide insights but might not be as effective as directly addressing the client.
B. While privacy is important, the spouse can often provide additional valuable information.
C. Explaining about post-MI depression is informative but does not directly assess the client's current emotional state.
D. Encouraging the client to describe his feelings allows the nurse to perform a thorough assessment of the client’s mental state and identify any signs of depression or anxiety.

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When entering the room of a sedated postoperative client, which assessment requires immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits Click to select the 5 most important nursing interventions for postoperative client care.

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

Explanation

Correct Answer is D

Explanation

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In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?

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