A nurse is assisting with the care of a client.

Exhibits
Which of the following actions should the nurse take to promote the client's respiratory status? Select all that apply.

Encourage the client to splint the abdomen when coughing.

Administer acetaminophen.

Administer ondansetron.

Remind the client to use the incentive spirometer five times per hr.

Encourage the client to cough and deep breathe.

Plan to ambulate the client 30 min after the next analgesic is administered.

Answer and Explanation

Correct Answer : A,D,E,F

A. Splinting the abdomen helps reduce pain during coughing, making it easier for the client to take deep breaths and effectively clear secretions. This is particularly important after abdominal surgery to minimize discomfort and promote effective coughing.

B. While acetaminophen can help with pain relief, it does not directly address the respiratory status of the client. Therefore, it is not a priority action in this context.

C. Ondansetron is effective for managing nausea, but it does not contribute to improving respiratory status directly. It is necessary for comfort, but it is not an action that promotes respiratory function.

D. The incentive spirometer is a valuable tool for encouraging deep breathing, which helps expand the lungs, improve ventilation, and prevent atelectasis (lung collapse). Regular use of the spirometer is crucial, especially in postoperative clients with decreased mobility.

E. Coughing and deep breathing are essential practices to prevent respiratory complications. They help clear secretions and promote lung expansion, which can improve oxygenation and respiratory function.

F. Ambulation is important for improving respiratory status by promoting lung expansion and circulation. It also aids in preventing complications such as deep vein thrombosis (DVT) and pneumonia. Planning ambulation after administering analgesics ensures that the client is more comfortable and able to participate in this activity.

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Correct Answer is D,E,A,C,B

Explanation

Begin by setting up a clean, dry surface above waist level to ensure sterility (Step D). Remove the dust cover and set up the sterile kit (Step E). Open the sterile kit's flaps in order, starting with the outermost (Steps A and C), and finally the innermost flap (Step B) while keeping distance to prevent contamination.

A. Provide the client with snug-fitting nightwear. B. Keep the door to the client's room closed. C. Administer prescribed diuretics in the evening. D. Use overhead lighting when checking equipment.

Correct Answer is B

Explanation

A. Providing snug-fitting nightwear may not help with insomnia; loose-fitting clothing is generally more comfortable for sleep.

B. Keeping the door to the client's room closed can help minimize disturbances and create a more tranquil environment, which is beneficial for a client with insomnia.

C. Administering diuretics in the evening can increase nighttime urination, which may exacerbate insomnia rather than alleviate it.

D. Using overhead lighting can disrupt the client's ability to relax and fall asleep; softer lighting is generally more conducive to a restful environment.

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A nurse is assisting with the care of a client. Exhibits Which of the following actions should the nurse take to promote the client's respiratory status? Select all that apply.

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A nurse is assisting with the care of a client.

Exhibits
Which of the following actions should the nurse take to promote the client's respiratory status? Select all that apply.