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 B

Explanation

An antibiotic that can cause nephrotoxicity is an antibiotic that can damage the kidneys, which are the organs that filter the blood and remove waste products and excess ﬂuid from the body. Some examples of nephrotoxic antibiotics are aminoglycosides, vancomycin, amphotericin B, and sulfonamides.

Serum creatinine is a laboratory value that measures the amount of creatinine in the blood. Creatinine is a waste product that is produced by the breakdown of muscle tissue and is normally excreted by the kidneys. A high serum creatinine level indicates that the kidneys are not functioning properly and are unable to filter out the creatinine from the blood.

Before administering an antibiotic that can cause nephrotoxicity, it is important for the practical nurse (PN) to review the serum creatinine level of the client, as it reﬂects the kidney function and the risk of nephrotoxicity. A normal serum creatinine level ranges from 0.6 to 1.2 mg/dL for men and 0.5 to 1.1 mg/dL for women. If the serum creatinine level is elevated, it may indicate that the client has impaired kidney function or is developing nephrotoxicity from the antibiotic. In this case, the PN should notify the primary healthcare provider and monitor the client for signs and symptoms of nephrotoxicity, such as decreased urine output, edema, hypertension, or electrolyte imbalances .

A. Remove indwelling urinary catheter when no longer indicated. B. Elevate affected limb at chest level. C. Assist the adolescent with ambulation from bed to chair. D. Perform neurovascular assessments every hour. E. Apply warm packs to right extremity for the first 24hrs

Correct Answer is ["A","C","D"]

Explanation

A. Remove indwelling urinary catheter when no longer indicated: This action prevents urinary tract infections and promotes bladder function.

B. Elevate affected limb at chest level: This action is contraindicated because it increases venous pressure and edema in the affected extremity, which could compromise blood flow and nerve function.
C. Assist the adolescent with ambulation from bed to chair: This action prevents complications such as deep vein thrombosis, pulmonary embolism, pneumonia, and constipation by enhancing circulation, respiration, and bowel motility.
D. Perform neurovascular assessments every hour: This action monitors for signs of impaired blood flow or nerve function in the affected extremity, such as changes in color, temperature, sensation, movement, or pulse.
E. Apply warm packs to right extremity for the first 24hrs: This action is contraindicated because it increases blood flow and edema in the affected extremity, which could compromise blood flow and nerve function.

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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

Before administering an antibiotic that can cause nephrotoxicity, which laboratory value is most important for the practical nurse (PN) to review?

Correct Answer is B

Explanation

Correct Answer is ["A","C","D"]

Explanation

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