A nurse is planning care for a client who is 4 hr postoperative. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

Give the client aback massage.

Teach the client relaxation techniques.

Assist the client to cough and deep breathe ev

Encourage the client to turn every 4 hr.

Administer PRN analgesics as needed.

Answer and Explanation

Correct Answer : A,B,C,E

A.   Postoperative patients often experience muscle tension and discomfort due to lying in one position for an extended period. A gentle back massage can help relieve muscle stiffness, promote relaxation, and improve circulation. It is a non-invasive comfort measure that can enhance the client's overall well- being.
B.   Teaching relaxation techniques such as deep breathing exercises, guided imagery, or progressive muscle relaxation can help the client manage pain, reduce anxiety, and promote faster recovery. These techniques are beneficial postoperatively as they encourage relaxation and improve overall comfort.
C.   Postoperative clients are at risk of developing respiratory complications such as atelectasis (partial lung collapse) or pneumonia due to shallow breathing or inadequate lung expansion. Coughing and deep breathing exercises help to clear secretions, improve lung function, and prevent respiratory complications. It is typically recommended to perform these exercises every hour to maintain lung expansion and prevent complications.
D.   Encouraging the client to turn every 2 hours (D), not every 4 hours, is essential to prevent pressure ulcers and promote circulation.
E.   Postoperative pain management is essential for the client's comfort and recovery. Pain can interfere with the client's ability to cough, deep breathe, and move effectively, which may increase the risk of complications. Administering analgesics as needed helps to control pain, improve overall comfort, and promote participation in necessary activities such as coughing, deep breathing, and turning.

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Correct Answer is A

Explanation

A. Assessing the airway is always a priority in any client care situation, especially when there are respiratory abnormalities such as respiratory acidosis. Ensuring a patent airway is crucial to maintain adequate oxygenation and ventilation.
B. Bronchodilators are typically used to treat conditions such as bronchoconstriction in asthma or chronic obstructive pulmonary disease (COPD). However, in the context of respiratory acidosis with an elevated PaCO2, the primary issue is not bronchoconstriction but rather impaired gas exchange due to inadequate ventilation.
C. Mucolytics are medications used to thin mucus and facilitate its removal from the respiratory tract. While they can be beneficial in conditions with thick secretions, they do not address the underlying cause of respiratory acidosis, which is inadequate CO2 elimination.
D. Providing oxygen can help improve oxygenation in clients with respiratory acidosis. However, it is important to note that oxygen alone will not correct the underlying cause of respiratory acidosis (elevated PaCO2). Oxygen therapy is supportive and helps to improve oxygen delivery to tissues while other interventions are addressed.

A. Metformin B. Carvedilol C. Atorvastatin D. Nitroglycerin

Correct Answer is A

Explanation

A. Metformin is an oral antidiabetic medication commonly used to manage type 2 diabetes mellitus. It can cause a rare but serious side effect called lactic acidosis, especially in situations where there is impaired kidney function or when the drug interacts with contrast dye used in procedures like cardiac catheterization.
B. Carvedilol is a beta-blocker used to manage hypertension and heart failure. It does not have a significant interaction with contrast dye that would increase the risk of AKI.
C. Atorvastatin is a statin medication used to lower cholesterol levels. It does not interact with contrast dye in a way that increases the risk of AKI.
D. Nitroglycerin is a vasodilator used to relieve angina symptoms. It does not interact with contrast dye in a way that increases the risk of AKI.

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A nurse is planning care for a client who is 4 hr postoperative. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

Nursing Test Bank

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