A nurse is providing preoperative teaching for a patient who is scheduled for a gastrectomy.
Which of the following information regarding the prevention of postoperative complications should the nurse include in the teaching?
Teach the client how to use the PCA pump.
Instruct the client on coughing and deep breathing exercises.
Explain the importance of early ambulation.
Discuss the use of incentive spirometry.
Correct Answer : B,C,D
Choice A rationale
While pain management is crucial postoperatively, teaching the client how to use a PCA pump does not directly prevent common postoperative complications like pneumonia, deep vein thrombosis, or wound infections. These complications are more directly addressed by respiratory exercises and early mobilization.
Choice B rationale
Instructing the client on coughing and deep breathing exercises is essential for preventing postoperative pulmonary complications such as atelectasis and pneumonia. These exercises help to expand the lungs, mobilize secretions, and improve oxygenation, reducing the risk of infection and respiratory distress.
Choice C rationale
Explaining the importance of early ambulation is vital in preventing several postoperative complications. Mobilization improves circulation, reducing the risk of deep vein thrombosis and pulmonary embolism. It also helps to promote bowel function and prevent constipation, as well as aiding in lung expansion and preventing atelectasis.
Choice D rationale
Discussing the use of incentive spirometry is important for preventing postoperative respiratory complications. Incentive spirometry encourages deep and sustained inhalation, which helps to expand the alveoli, improve lung volume, and prevent atelectasis and pneumonia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Decreased right knee range of motion is a common finding in older adults due to age-related degenerative changes like osteoarthritis. While it warrants assessment, it does not necessarily indicate an acute issue requiring immediate intervention unless accompanied by pain, swelling, or functional limitations.
Choice B rationale
Report of left hip aching when jogging could be related to musculoskeletal issues like arthritis or muscle strain, which are not uncommon in older adults. Further assessment is needed to determine the cause and appropriate management, but it does not immediately signal a critical issue requiring urgent intervention.
Choice C rationale
A history of recent loss of balance and a fall in a 77-year-old patient is a significant finding that requires further nursing assessment and intervention. Falls in older adults can lead to serious injuries such as fractures, and a recent history suggests an underlying issue affecting stability and safety. This necessitates investigation into potential causes and implementation of fall prevention strategies.
Choice D rationale
Occasional mild constipation is a common complaint among older adults due to factors like decreased physical activity, dietary changes, and medication side effects. While it should be addressed with appropriate interventions like increased fiber and fluids, it does not typically require immediate or urgent nursing intervention unless it is severe or accompanied by other concerning symptoms. .
Correct Answer is A
Explanation
Choice A rationale
A 24-hour urinary output of 380 mL falls below the generally accepted threshold for oliguria in adults. This reduced output could indicate kidney dysfunction or decreased renal perfusion following surgery.
Choice B rationale
A 24-hour urinary output of 600 mL is within the low end of the normal range for adult urinary output, which is generally considered to be 800 mL to 2000 mL per 24 hours.
Choice C rationale
A 24-hour urinary output of 550 mL is also within the low end of the normal range for adult urinary output. While lower than average, it does not meet the criteria for oliguria.
Choice D rationale
A 24-hour urinary output of 720 mL is within the normal range for adult urinary output and does not indicate oliguria.
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