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. Metabolic acidosis is characterized by a low pH (<7.35) and a decreased bicarbonate (HCO3) level (<22 mEq/L). The ABG results show a pH of 7.30 and HCO3 of 18 mEq/L, which are consistent with metabolic acidosis. The low HCO3 indicates that there is an accumulation of acids or loss of bicarbonate in the blood.
B. Metabolic alkalosis is characterized by a high pH (>7.45) and an elevated bicarbonate level (>26 mEq/L). The ABG results show a low pH and low HCO3, which do not support metabolic alkalosis.
C. Respiratory alkalosis is characterized by a high pH (>7.45) and a low PaCO2 (<35 mm Hg). The pH in this scenario is low (7.30), which does not align with respiratory alkalosis.
D. Respiratory acidosis is characterized by a low pH (<7.35) and an elevated PaCO2 (>45 mm Hg). While the pH is low, indicating acidosis, the PaCO2 in this case is low (28 mm Hg), which does not support respiratory acidosis.

A. Hypophosphatemia B. Hypernatremia C. Hypercalcemia D. Hyperkalemia

Correct Answer is D

Explanation

A. Hypophosphatemia refers to low levels of phosphate in the blood. In prerenal AKI, phosphate levels are typically normal or even elevated due to reduced kidney function and impaired phosphate excretion. Therefore, hypophosphatemia is not expected in prerenal AKI.
B. Hypernatremia refers to high levels of sodium in the blood. In prerenal AKI, sodium levels can be elevated due to reduced kidney function and impaired ability to excrete sodium. This occurs because the kidneys play a crucial role in regulating sodium balance. Therefore, hypernatremia is a possible electrolyte imbalance in prerenal AKI.
C. Hypercalcemia refers to high levels of calcium in the blood. In prerenal AKI, calcium levels are usually normal or decreased due to various factors, including reduced renal excretion of calcium. Therefore, hypercalcemia is not typically seen in prerenal AKI.
D. Hyperkalemia refers to high levels of potassium in the blood. In prerenal AKI, hyperkalemia is a common electrolyte imbalance. Normally, the kidneys play a critical role in potassium excretion. Reduced kidney function in prerenal AKI can lead to impaired potassium excretion, resulting in elevated potassium levels in the blood.

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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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Explanation

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