A nurse is developing a plan of care for an 80-year-old client who is postoperative. This client has a 38 pack-year smoking history. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?
Place suction equipment at the bedside.
Perform range of motion (ROM) exercises.
Administer an expectorant.
Encourage the use of incentive spirometry.
The Correct Answer is D
Choice A reason: Placing suction equipment at the bedside is a preparatory measure but not a preventive intervention for pulmonary complications.
Choice B reason: Performing ROM exercises is beneficial for overall mobility but does not directly prevent pulmonary complications.
Choice C reason: Administering an expectorant may help clear secretions but is not the primary preventive measure for pulmonary complications.
Choice D reason: Encouraging the use of incentive spirometry is a proven intervention to prevent pulmonary complications by promoting lung expansion and preventing atelectasis, especially in patients with a history of smoking.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: While blood pressure is important, hyperkalemia can cause cardiac dysrhythmias, making the pulse rate the first assessment to ensure the patient's immediate safety.
Choice B reason: Temperature is not directly affected by serum potassium levels and is not the priority in hyperkalemia.
Choice C reason: Respirations are less likely to be affected immediately by hyperkalemia compared to cardiac function.
Choice D reason: A high serum potassium level can lead to life-threatening cardiac arrhythmias, so assessing the pulse rate is the most critical initial action.
Correct Answer is D
Explanation
Choice A reason: Lethargy implies a state of sluggishness, drowsiness, or fatigue, not the inability to respond to stimuli.
Choice B reason: Stupor refers to a state of near-unconsciousness or insensibility, but the patient may respond to vigorous stimulation.
Choice C reason: Obtundation describes a state of consciousness characterized by a reduced alertness and a slow response to stimuli, but not complete unresponsiveness.
Choice D reason: Comatose is the correct term for a state of deep unconsciousness in which a patient cannot be aroused, fitting the description of the patient's condition.
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