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 C

Explanation

A. Potassium levels are important for assessing electrolyte balance and are not directly indicative of protein intake or synthesis.
B. Calcium levels are important for bone health, nerve function, and muscle contraction. They are not directly indicative of protein intake or synthesis.
C. Albumin is a plasma protein that reflects the body's nutritional status and liver function. It has a relatively long half-life (approximately 20 days), making it a useful marker for assessing protein intake and synthesis over time. Low albumin levels can indicate malnutrition, liver disease, or other conditions affecting protein metabolism.
D. Sodium levels are important for fluid balance and nerve function. They are not directly indicative of protein intake or synthesis.

A. To determine how the client will tolerate the procedure B. To establish a baseline for postoperative assessment C. To prevent postoperative hypotension D. To assess the client's pain level

Correct Answer is B

Explanation

A. Vital signs, including blood pressure, heart rate, respiratory rate, and temperature, provide baseline information about the client's cardiovascular and respiratory status. This assessment helps predict how well the client might tolerate the surgical procedure under anesthesia and monitor for any deviations during the procedure.
B. Establishing baseline vital signs before surgery provides a comparison point for monitoring the client's recovery and identifying any postoperative complications. Changes in vital signs postoperatively can indicate potential issues such as bleeding, fluid imbalance, or respiratory compromise.
C. Monitoring blood pressure before surgery helps identify clients at risk for intraoperative hypotension, particularly important during induction of anesthesia and throughout the surgical procedure. Establishing baseline blood pressure levels guides intraoperative management to maintain hemodynamic stability.
D. While vital signs are important for assessing physiological status, they do not directly assess pain. Pain assessment involves asking the client about their pain experience, location, intensity, and factors that alleviate or exacerbate pain. Vital signs can indirectly reflect pain if pain causes changes in heart rate or blood pressure, but they are not specific indicators of pain.

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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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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.)