A nurse is updating a postoperative client's plan of care. The nurse should include which of the following as the priority interventions?

Reposition the client frequently.

Instruct the client to use the incentive spirometer.

Increase the amount of time the client spends out of bed each day.

Ensure the client consumes an adequate amount of fluids.

Answer and Explanation

The Correct Answer is B

A.   Reposition the client frequently: While repositioning is important for preventing pressure ulcers and maintaining comfort, it may not be the priority immediately postoperatively compared to other interventions.
B.   Instruct the client to use the incentive spirometer: This is the correct answer. Incentive spirometry helps prevent atelectasis and respiratory complications postoperatively, making it a priority intervention to include in the plan of care.
C.   Increase the amount of time the client spends out of bed each day: Early ambulation is important for preventing complications such as deep vein thrombosis and pneumonia, but it may not be the priority immediately postoperatively depending on the client's condition and surgical procedure.
D.   Ensure the client consumes an adequate amount of fluids: While hydration is important for postoperative recovery, ensuring adequate fluid intake may not be the priority compared to interventions aimed at preventing respiratory complications such as atelectasis.

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Correct Answer is B

Explanation

A. Instruct the AP to request assistance when unsure about a task: While this is an important instruction, the immediate priority is ensuring the safety of the client during the transfer.
B. Help the AP assist the client with the transfer: This is the correct answer. The nurse should intervene immediately to ensure the safety of the client during the transfer. Providing assistance to the AP in safely transferring the client is the most appropriate action to take first.
C. Refer the AP to the facility procedure manual: While facility procedures are important, referring to the manual may not address the immediate need to correct the incorrect transfer and ensure client safety.
D. Demonstrate the proper client transfer technique for the AP: While education and demonstration of correct techniques are important, the immediate priority is to intervene and ensure the safety of the client during the transfer.

A. Notify risk management before initiating treatment. B. Contact the client's next of kin to obtain consent for treatment. C. Proceed with treatment without obtaining written consent. D. Have the client sign a consent for treatment.

Correct Answer is C

Explanation

A. Notify risk management before initiating treatment: While risk management may need to be involved in certain situations, the priority in this case is to address the client's immediate medical needs.
B. Contact the client's next of kin to obtain consent for treatment: In emergency situations where the client is unable to provide consent and there is no surrogate decision-maker available,
healthcare providers are generally authorized to proceed with necessary treatment to stabilize the patient.
C. Proceed with treatment without obtaining written consent: This is the correct answer. In emergencies where immediate treatment is required to prevent further harm or stabilize the patient's condition, obtaining written consent may not be feasible or appropriate.
D. Have the client sign a consent for treatment: If the client is disoriented and has a cardiac arrhythmia, they may not be capable of providing informed consent at that moment. Therefore, waiting for them to sign a consent form could delay necessary treatment.

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A nurse is updating a postoperative client's plan of care. The nurse should include which of the following as the priority interventions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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