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Palliative surgery prioritizes symptom relief, not diagnostic data collection. Procedures like biopsies aim to gather information for medical planning, not alleviate symptoms. Palliative surgery addresses issues like pain or obstruction in terminal conditions, improving quality of life without curing, making this choice incorrect for palliative rationale.

Elective procedures for improving body structures, like cosmetic surgery, are not palliative. Palliative surgery focuses on symptom relief in serious illnesses, not aesthetic enhancements. This choice is irrelevant, as palliative care aims to manage symptoms like pain or obstruction, not improve physical appearance or structure.

Repairing deformities from birth or disease is linked to reconstructive surgery, not palliative care. Palliative surgery relieves symptoms like pain or obstruction without addressing the underlying cause, unlike corrective procedures, making this choice inappropriate for the rationale of a palliative surgical procedure.

Notifying the provider is important but not the first step. Measuring arm circumference provides objective data to report accurately. Swelling may indicate thrombosis or infection, but without measurements, premature notification lacks specificity, potentially delaying interventions based on clinical findings and diagnostic confirmation.

Removing the PICC line is premature without confirming the cause of swelling. Thrombosis, infection, or mechanical issues could cause swelling, but removal risks complications like bleeding. Assessment, like measuring arm circumference, is needed first to determine if removal or other interventions are warranted.

Applying a cold pack may reduce swelling but does not address underlying causes like thrombosis or infection. Without assessing the extent and cause of swelling, this intervention is inappropriate as a first step. Objective data collection, like measuring arm circumference, guides effective treatment and prevents complications.

Wheezes are high-pitched, musical sounds caused by narrowed airways, common in asthma or COPD exacerbations. They do not clear with coughing and are not moist or rumbling, making this an incorrect description for the lung sounds heard, which improve after coughing in this COPD client.

Crackles are fine or coarse popping sounds caused by fluid in smaller airways or alveoli, often in pneumonia or heart failure. They do not clear with coughing and are not rumbling, making crackles an incorrect choice for the moist, rumbling sounds that improve after coughing.

Pleural friction rub is a grating sound caused by inflamed pleural surfaces, often in pleurisy. It is not moist or rumbling and does not improve with coughing, making it an inappropriate description for the lung sounds heard in this client with COPD, which are secretion-related.

Rolled gauze and sterile saline are used for general wound care but are inadequate for chest tube emergencies. If a tube dislodges, an occlusive dressing prevents air entry into the pleural space, avoiding pneumothorax, making this choice insufficient for emergency preparedness in chest tube management.

Suction tubing and Yankauer suction tip clear oral or airway secretions, not chest tube issues. They are irrelevant for emergencies like tube dislodgement, where sealing the pleural space prevents pneumothorax, making this choice inappropriate for chest tube emergency preparedness in this scenario.

Non-adhesive dressings and tracheostomy tubes are for tracheostomy care, not chest tubes. They do not address emergencies like tube dislodgement, which require an occlusive dressing to prevent air entry, rendering this choice incorrect for chest tube emergency preparedness in this context.

Serosanguineous drainage less than 70 mL/hr is normal for a chest tube, indicating expected postoperative or pleural fluid drainage. It does not suggest complications like excessive bleeding or infection, so no immediate intervention is required, making this finding benign compared to an air leak.

Mild chest discomfort during coughing or deep breathing is expected with a chest tube, as it irritates the pleural space. This does not indicate a complication requiring intervention, as it reflects normal tissue response to the tube, manageable with pain relief, not urgent action.

Small crepitus around the insertion site indicates subcutaneous emphysema, where air escapes into tissues. While concerning, small amounts often resolve spontaneously as the lung heals. It requires monitoring but not immediate intervention, unlike vigorous bubbling, which signals a critical air leak requiring urgent action.

Oxygen and suction equipment support respiratory function but are not the priority for opioid-induced respiratory depression from morphine. Lethargy and low respiratory rate (8 breaths/min) indicate overdose, requiring naloxone to reverse opioid effects first, as hypoxia can persist without addressing the primary cause.

IV fluids may support blood pressure but are not the priority for opioid-induced respiratory depression. Lethargy and low respiratory rate indicate morphine toxicity, requiring naloxone to reverse effects. Fluids address secondary issues like hypovolemia, not the primary concern of respiratory compromise in this case.

A blood pressure monitor is unnecessary, as the client’s blood pressure (118/66) is stable. The critical issue is respiratory depression and lethargy from morphine, requiring naloxone. Monitoring blood pressure is secondary to addressing life-threatening respiratory compromise caused by opioid overdose in this postoperative client.

Dilated and reactive pupils are unrelated to albuterol’s effect. Albuterol, a bronchodilator, relaxes bronchial smooth muscles to improve airflow in emphysema. Pupil changes may indicate neurological or systemic issues but are not a direct indicator of albuterol’s effectiveness in relieving bronchoconstriction and respiratory distress.

Urine output of 50 mL/hr is normal but unrelated to albuterol’s effect. Albuterol targets bronchial smooth muscles to relieve bronchoconstriction in emphysema, improving respiratory function. Urine output reflects renal function, not airway improvement, making it an irrelevant indicator of albuterol’s therapeutic effectiveness in this context.

A heart rate of 100 beats/minute may occur as a side effect of albuterol’s beta-adrenergic stimulation but is not the primary therapeutic indicator. Albuterol aims to improve airflow and reduce respiratory distress, evidenced by a decreased respiratory rate, not tachycardia, which is a secondary effect.

Reducing anxiety about tracheostomy self-care aids long-term adjustment but is not the immediate priority. A new tracheostomy requires vigilant monitoring for complications like infection or skin breakdown at the stoma, which can lead to serious infections or tissue damage if not addressed promptly.

Reassuring the client that the tracheostomy is temporary may provide emotional support but is not the priority. Many tracheostomies are permanent, and assuming temporariness may mislead. Immediate care focuses on preventing complications like stoma infections, making skin assessment more critical than reassurance.

Referring to a support group aids long-term coping but is not the immediate priority. A new tracheostomy requires focus on preventing physical complications like infection or skin breakdown at the stoma, which pose immediate risks, making skin assessment more urgent than psychosocial support.

Decreasing fluid intake is appropriate for hypervolemia, as excess fluid exacerbates conditions like heart failure, causing edema and hypertension. Limiting fluids reduces fluid overload, preventing complications like pulmonary edema, indicating the client understands this aspect, requiring no further teaching on this point.

Avoiding high-sodium foods is correct, as sodium retains water, worsening hypervolemia. Reducing sodium prevents fluid retention, lowering risks of edema and heart failure exacerbation, showing the client understands this self-management strategy, making further teaching unnecessary for this aspect of hypervolemia care.

Calling the physician for swelling is appropriate, as edema indicates fluid retention in hypervolemia. Prompt reporting allows early intervention to prevent complications like heart failure, showing the client understands this action, requiring no further teaching on reporting symptoms for timely medical management.