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 C

Explanation

A. Consult the pharmacist about the client's prescribed medications: While consulting the pharmacist may provide valuable information about the medications, it may not be the first action to take in this scenario.
B. Call the provider to clarify the client's prescribed medications: While it may be necessary to clarify the client's medications with the provider, it may not be the first action to take, especially if there are discrepancies in the documentation.
C. Compare the client's medication administration record with the prescriptions on the transfer orders: This is the correct answer. Comparing the client's medication administration record with the prescriptions on the transfer orders can help identify any discrepancies or errors in medication administration, ensuring patient safety and adherence to prescribed therapy.
D. Review the intended purpose of the prescribed medications with the client: While reviewing the intended purpose of the medications with the client is important for informed decision-making, it may not be the first action to take if there are concerns about the accuracy or appropriateness of the prescribed medications.

A. Document the client's refusal in their chart. B. Tell the client that their blood alcohol level will be checked. C. Assess the client for urinary retention. D. Inform the client that a catheter will be inserted.

Correct Answer is A

Explanation

A. Documenting the client's refusal in their chart is crucial for maintaining accurate records and ensuring that the refusal is properly documented for legal and medical purposes.
B. While checking the client's blood alcohol level may be relevant to the situation, it should not be done without the client's consent or a valid medical reason.
C. Assessing the client for urinary retention is not indicated in this scenario, as the client's refusal to provide a urine sample does not necessarily indicate urinary retention.
D. Informing the client that a catheter will be inserted without their consent is not appropriate and violates the client's autonomy.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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