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. Diarrhea can lead to loss of bicarbonate from the body, resulting in metabolic acidosis. The loss of bicarbonate through gastrointestinal fluids causes an imbalance between acids and bases in the body.
B. Salicylates (such as aspirin) can cause metabolic acidosis by several mechanisms, including direct stimulation of the respiratory center in the brainstem (leading to hyperventilation and respiratory alkalosis initially) and later causing metabolic acidosis due to increased production of acids like lactic acid and ketoacids.
C. Vomiting can lead to loss of gastric acid (hydrochloric acid), which could initially lead to metabolic alkalosis due to loss of acid.
D. Thiazide diuretics can cause metabolic alkalosis rather than metabolic acidosis. They promote the loss of potassium and hydrogen ions (acid), leading to increased blood pH (alkalosis).

A. Assessment B. Planning C. Implementation D. Evaluation

Correct Answer is A

Explanation

A. Assessment is the first phase of the nursing process where the nurse collects data about the client's health status, including medical history, current symptoms, and potential allergies. During the assessment phase, the nurse should specifically ask the client about any known allergies to medications, foods, or other substances. This information is crucial for ensuring patient safety during diagnostic testing and any subsequent treatments.
B. The planning phase involves developing a care plan based on the assessment data gathered. While the nurse does consider potential allergies during this phase when planning interventions and care strategies, the primary focus is on creating a plan that addresses the client's specific needs and goals.
C. Implementation is the phase where the nurse carries out the interventions outlined in the care plan. If the client has allergies identified during the assessment phase, the nurse must ensure that these allergies are communicated to the healthcare team and that appropriate precautions are taken during diagnostic testing and any procedures or treatments.

D. Evaluation is the final phase of the nursing process where the nurse assesses the client's response to interventions and determines the effectiveness of the care plan. Although allergies are primarily addressed in the assessment phase, the nurse continues to monitor for allergic reactions throughout the client's care and promptly addresses any concerns that arise.

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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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