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.
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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Related Questions
Correct Answer is D
Explanation
A. While it is advisable for individuals to review legal documents with their attorney, it does not directly indicate understanding of advance directives.
B. Selecting a family member as a healthcare proxy is a component of advance directives but does not directly indicate understanding of the concept.
C. Having a nurse witness the signing of a living will is not a typical requirement for advance directives and does not necessarily indicate understanding of the process.
D. This statement demonstrates an understanding that advance directives are not necessarily permanent and can be modified or revoked by the individual at any time while they have decision-making capacity. This reflects comprehension of the flexibility and autonomy inherent in advance directives.
Correct Answer is B
Explanation
A. A client who has dementia and exhibits aphasia: While aphasia can be concerning, it is not necessarily indicative of immediate risk to the client or others.
B. A client who has bipolar disorder and displays constant pacing: This client is the highest priority because constant pacing may indicate agitation or escalating anxiety, which could lead to agitation or aggression and require immediate intervention to prevent harm to the client or others.
C. A client who has schizophrenia and uses neologisms: Neologisms, although indicative of disorganized thinking, do not necessarily present an immediate safety concern compared to constant pacing.
D. A client who has depressive disorder and has poor personal hygiene: While poor personal hygiene is important to address for the client's well-being, it may not present an immediate safety risk compared to the behaviors exhibited by the client in option B.
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