Exhibits

A nurse is providing care for a preschooler who has acute gastroenteritis. Which of the following actions should the nurse take? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

A. "I wonder if the metal in my knee will show up in airport screenings.": This statement reflects curiosity and does not indicate a lack of understanding of the procedure or its risks.

B. "The physical therapy has not been working, so I will need to have the surgery.": The client is expressing a reason for pursuing surgery, which shows understanding of the indication and is appropriate.

C. "I look forward to being able to bend my knee again when I sit in a chair.": This statement demonstrates realistic expectations for postoperative outcomes, indicating understanding of the procedure’s benefits.

D. "I am thankful there are no serious complications from this type of surgery.": This statement indicates a misunderstanding of informed consent. The client shows a lack of awareness that all surgeries carry potential risks. The nurse should contact the surgeon to ensure the client fully understands possible complications before signing.

A. Determine the client's airway patency: Ensuring the airway is patent is the highest priority in the immediate postoperative period because airway compromise can be life-threatening. This assessment is performed first to address the most critical physiological need.

B. Evaluate the client's level of consciousness: After airway and basic respiratory assessment, the nurse evaluates the client’s level of consciousness to detect neurological changes, sedation effects from anesthesia, or potential complications.

C. Auscultate the client's lung sounds: Respiratory assessment, including auscultation, identifies complications such as atelectasis or pneumonia. While vital, it follows confirming airway patency to prioritize immediate safety.

D. Ask the client to rate their pain: Pain assessment is important for comfort and recovery but is performed after addressing airway, breathing, and neurological status. It is lower priority compared with immediate physiological needs.