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 C
Explanation
Choice A reason: Respiratory Acidosis is characterized by a low pH and a high PCO2, which is not the case here.
Choice B reason: Respiratory Alkalosis would involve a high pH and a low PCO2, which is not consistent with the patient's PCO2 level.
Choice C reason: Metabolic Alkalosis is indicated by a high pH and a high HCO3, which matches the patient's blood gas values.
Choice D reason: Metabolic Acidosis would show a low pH and a low HCO3, which is the opposite of this patient's presentation.
Correct Answer is C
Explanation
Choice A reason: Taking several deep breaths is not specifically related to the preparation for a renal system physical assessment. Deep breaths are more commonly associated with lung examination or to help the patient relax.
Choice B reason: Drinking several glasses of water before a renal assessment could potentially fill the bladder, which might interfere with palpation of the kidneys and make it uncomfortable for the patient.
Choice C reason: Emptying the bladder is the correct action before a renal system physical assessment. It allows for better palpation of the kidneys and other structures without the discomfort of a full bladder. It also prevents the possibility of the patient urinating involuntarily during the examination due to a full bladder.
Choice D reason: Providing a urine sample might be part of the overall renal assessment, but it is not necessary to do so immediately before the physical examination of the renal system. The sample can be collected at any time before or after the physical examination.
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