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 D

Explanation

A. Respiratory alkalosis is characterized by a high pH (alkaline) and a low PaCO2 (<35 mm Hg). The ABG results provided show a pH of 7.3 (which is acidic) and a PaCO2 of 50 mm Hg (which is elevated). Therefore, these results do not indicate respiratory alkalosis.
B. Metabolic acidosis is characterized by a low pH (<7.35) and a decreased bicarbonate (HCO3-). The ABG results show a pH of 7.3 (acidic), which aligns with metabolic acidosis. However, the PaCO2 of 50 mm Hg is elevated, which typically indicates respiratory compensation for the metabolic acidosis.
C. Metabolic alkalosis is characterized by a high pH and an elevated bicarbonate (HCO3-). The ABG results show a pH of 7.3 (acidic), which does not suggest metabolic alkalosis.
D. Respiratory acidosis is characterized by a low pH and an elevated PaCO2 (>45 mm Hg). The ABG results provided show a pH of 7.3 (acidic) and a PaCO2 of 50 mm Hg (elevated). These findings are consistent with respiratory acidosis, where the elevated PaCO2 indicates retention of carbon dioxide, leading to acidosis.

A. Potassium: 2.9 mEq/L (2.9 mm) B. Creatinine: 1.2 mg/dL (106.1 umol/L) C. Hemoglobin: 14.8 mg/dL (148 mmol/L) D. Sodium: 134 mEq/L (134 mmol/L)

Correct Answer is A

Explanation

A. A potassium level of 2.9 mEq/L is below the normal range (typically 3.5-5.0 mEq/L). Abnormal potassium levels can affect cardiac function, leading to arrhythmias (irregular heartbeats), especially if the potassium level drops further or if there is rapid fluctuation. This is a critical finding that requires immediate attention from the surgical team to assess the client's cardiac status and determine if potassium replacement is needed before proceeding with surgery.
B. Creatinine levels are used to assess kidney function. A creatinine level of 1.2 mg/dL is within the normal range (typically 0.6-1.2 mg/dL). While kidney function is important to evaluate before surgery, this result is not immediately concerning enough to require an urgent call to the surgical team.
C. Hemoglobin levels are assessed to evaluate oxygen-carrying capacity of the blood. A hemoglobin level of 14.8 g/dL is within the normal range (typically 12-16 g/dL for women and 13-18 g/dL for men). This result indicates adequate oxygen-carrying capacity and does not require immediate communication with the surgical team.

D. Sodium levels are important for fluid balance and nerve function. A sodium level of 134 mEq/L is within the normal range (typically 135-145 mEq/L). While sodium levels should be monitored, this result is not critically abnormal and does not necessitate an urgent call to the surgical team.

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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.)

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