Which of the following does the nurse implement to prevent postoperative respiratory complications for a patient? (Select all that apply)

Choice A reason: Evaluation is the final step of the nursing process, where the nurse determines the effectiveness of the nursing care provided.

Choice B reason: Assessment is the correct part of the nursing process for the mental status examination, as it involves collecting data about the patient.

Choice C reason: Planning involves setting goals and choosing appropriate nursing actions based on the assessment data.

Choice D reason: Implementation is the step where the nurse carries out the planned interventions.

Choice A reason: Fecal impaction typically presents with the inability to pass stool and may not be associated with the absence of bowel sounds.

Choice B reason: Incisional infection is usually indicated by localized redness, warmth, and possible discharge, not necessarily by the absence of bowel sounds or flatus.

Choice C reason: Health care-associated Clostridium difficile often presents with diarrhea, not the absence of bowel sounds or flatus.

Choice D reason: Paralytic ileus is characterized by impaired intestinal motility and transit, absence of the passage of flatus, diminished bowel sounds, abdominal distension, and intestinal dilatation, fitting the symptoms described.