A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the following actions is the nurse's priority?

Assess fluid intake every 24 hr.

Ambulate three times a day.

Assist with deep breathing and coughing.

Monitor the incision site for findings of infection.

Answer and Explanation

The Correct Answer is C

A. Assessing fluid intake every 24 hr is important for a postoperative client, but it is not the priority action. The nurse should monitor fluid intake and output more frequently, such as every 8 hr or every shift, to detect any imbalances or complications.

B. Ambulating three times a day is beneficial for a postoperative client, but it is not the priority action. The nurse should encourage early and frequent ambulation to promote circulation, prevent thromboembolism, and enhance bowel function, but only after ensuring that the client is stable and has adequate pain control.

C. Assisting with deep breathing and coughing is the priority action for a postoperative client who had abdominal surgery. The nurse should help the client perform these exercises every 1 to 2 hr to prevent atelectasis, pneumonia, and respiratory failure, which are common and serious complications after abdominal surgery.

D. Monitoring the incision site for findings of infection is important for a postoperative client, but it is not the priority action. The nurse should inspect the wound for signs of infection, such as redness, swelling, warmth, drainage, or odor, but this can be done during routine dressing changes or as needed.

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Correct Answer is D

Explanation

A. Obesity is not a risk factor for osteoporosis. In fact, obesity may have a protective effect on bone density due to increased mechanical loading and higher levels of estrogen in adipose tissue.

B. Acromegaly is not a risk factor for osteoporosis. Acromegaly is a condition caused by excess growth hormone, which leads to increased bone formation and remodeling.

C. Estrogen replacement therapy is not a risk factor for osteoporosis. Estrogen replacement therapy can help prevent bone loss and reduce the risk of fractures in postmenopausal women with low estrogen levels.

D. Sedentary lifestyle is a risk factor for osteoporosis. Sedentary lifestyle reduces physical activity and muscle strength, which decreases bone stimulation and increases bone resorption.

A. Increased food intake B. Can perform ADLS independently C. Improved short-term memory D. Enhanced mood

Correct Answer is C

Explanation

Choice A reason

Increased food intake does not show medication is effective: Increased food intake is not a specific indication of donepezil's effectiveness. While some clients with dementia may have improved appetite due to reduced agitation or confusion, it is not directly related to the medication's therapeutic effect.

Choice B reason:

Can perform ADLs independently is inappropriate: The ability to perform activities of daily living (ADLs) independently can be a positive outcome in clients with dementia. However, it may not be solely attributed to donepezil, as ADLs can be influenced by various factors, including the client's overall condition and support received.

Choice C reason:

Improved short-term memory is correct. One of the primary goals of using donepezil is to improve memory and slow the decline in cognitive abilities associated with dementia. Therefore, if a client shows improvement in short-term memory, it suggests that the medication is having a positive effect in preserving cognitive function.

Choice D reason

Enhanced mood does not show the medicine is effective: Donepezil is primarily aimed at improving cognitive function and memory, and its effects on mood may be limited. While some clients may experience mood improvements due to reduced frustration or confusion from memory loss, it is not the primary indicator of the medication's effectiveness.

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A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the following actions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a client education program about osteoporosis for older adult clients. The nurse should include which of the following variables as a risk factor for osteoporosis?

Correct Answer is D

Explanation

A nurse in a long-term care facility is providing care for a client who has been receiving donepezil. Which of the following findings indicates that the medication is effective?

Correct Answer is C

Explanation

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