A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?

Administer an expectorant

Perform range-of-motion exercises

Place suction equipment at the bedside

Encourage the use of an incentive spirometer

Answer and Explanation

The Correct Answer is D

A. Administering an expectorant is not primarily aimed at preventing pulmonary complications but rather at helping to clear mucus. While this can be part of respiratory care, it does not address the prevention of complications like atelectasis or pneumonia.

B. Performing range-of-motion exercises is important for overall mobility and prevention of deep vein thrombosis but does not specifically address the prevention of pulmonary complications.

C. Placing suction equipment at the bedside is useful for managing secretions but does not directly prevent pulmonary complications. It is a reactive measure rather than preventive.

D. Encouraging the use of an incentive spirometer is an effective method to prevent pulmonary complications such as atelectasis and pneumonia. It helps improve lung function by promoting deep breathing and expanding the alveoli.

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Correct Answer is A

Explanation

A. Chvostek's sign is a test for tetany, which is associated with hypocalcemia. The tingling sensation reported by the client is indicative of low calcium levels, and Chvostek's sign involves tapping the facial nerve to see if it triggers facial twitching, which is a sign of hypocalcemia.

B. Kernig's sign is used to assess for meningitis and is not related to hypocalcemia. It involves checking for resistance or pain when extending the leg while the hip is flexed.

C. Babinski's sign is used to assess for neurological conditions and is not related to hypocalcemia. It involves stroking the sole of the foot to check for abnormal reflex responses.

D. Brudzinski's sign is used to assess for meningitis and involves checking for involuntary flexion of the knees and hips when the neck is flexed. It is not related to the symptoms of hypocalcemia.

A. Reduce the client's intake of protein. B. Restrict the client's intake of fluids. C. Administer vitamin K D. Administer diuretics.

Correct Answer is A

Explanation

A. Reducing protein intake is a key intervention to decrease ammonia levels in clients with liver cirrhosis and encephalopathy. Protein metabolism in the liver produces ammonia, and limiting protein can help manage elevated ammonia levels, thereby reducing symptoms of encephalopathy.

B. Restricting fluid intake is not directly related to decreasing ammonia levels. While fluid restriction may be necessary in cases of ascites or edema, it does not address the root cause of elevated ammonia in liver disease.

C. Administering vitamin K is important for managing clotting issues in liver disease but does not directly impact ammonia levels. Vitamin K helps with clotting factor synthesis, which is not directly related to ammonia metabolism.

D. Administering diuretics can help manage fluid retention but does not reduce ammonia levels. The primary goal for managing ammonia in cirrhosis involves dietary modifications and medications like lactulose, rather than diuretics.

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A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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