Share This Link

This statement reflects negative self-perception and lack of adaptation, indicating the client is struggling with their new identity.

Avoiding socialization suggests the client has not yet accepted their condition or reintegrated into their normal social roles.

While acceptance is noted, the belief that they are entirely incapable of self-care shows dependence and a lack of role adaptation.

Bradycardia is a possible side effect but is less immediately dangerous than impaired breathing.

Hypotension can occur with morphine use, but it is typically manageable and not as urgent as respiratory depression.

Pruritus (itching) is a common, non-life-threatening side effect of morphine and can usually be treated symptomatically.

Discontinuing IV fluids immediately upon arrival to the PACU is inappropriate, as the client may still need fluid support until they are fully stable and able to tolerate oral intake.

Checking vital signs only once every hour is too infrequent in the immediate postoperative phase. Vital signs should be monitored every 15 minutes initially.

Maintaining a supine position is not ideal after general anesthesia due to the risk of airway obstruction. A lateral or semi-Fowler's position is safer to promote airway patency.

Instructing the client to take shallow, rapid breaths is incorrect; deep breathing is encouraged to promote effective airway clearance.

Percussing over each area for 10 minutes is excessive and could cause discomfort or injury; typically, 1 to 2 minutes per area is sufficient.

Maintaining positioning for 45 minutes is unnecessary and could lead to discomfort or skin breakdown; position changes should occur more frequently.

Raising the drainage system to chest level is incorrect and can cause backflow of fluid or air into the pleural space, increasing the risk of pneumothorax.

Squeezing the tubing is not a recommended practice and can cause increased intrathoracic pressure or damage the drainage system.

The collection chamber is not emptied; instead, the entire drainage system is replaced when full to maintain sterility and function.

Inserting central lines into the femoral vein, especially in obese clients, increases the risk of infection and is not recommended as best practice.

Performing hand hygiene for only 10 seconds is insufficient. Current guidelines recommend washing hands for at least 20 seconds to effectively reduce the spread of pathogens.

Keeping intubated clients in the supine position increases the risk of ventilator-associated pneumonia (VAP). The head of the bed should be elevated 30 to 45 degrees to prevent infection.

A platelet count of 325,000/mm³ is within the normal range and does not indicate a complication of cirrhosis.

An albumin level of 4.8 g/dL is normal; hypoalbuminemia, not a normal level, would be a concern in cirrhosis due to impaired liver protein synthesis.

A WBC count of 8,000/mm³ is within the normal range and does not reflect a complication of cirrhosis.

Acute respiratory distress syndrome (ARDS) typically leads to hypoxemia and respiratory acidosis due to impaired gas exchange, not respiratory alkalosis.

Excessive intake of bicarbonate causes metabolic alkalosis, not respiratory alkalosis.

Kyphosis can restrict lung expansion, resulting in hypoventilation and respiratory acidosis, not alkalosis.