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. 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.

A. Send the facility a copy of the client's complete medical record. B. Avoid using a fax cover sheet in order to reduce paper waste. C. Call the facility to confirm the fax number after sending the client's information. D. Shred extra copies of the client's records when they are no longer needed.

Correct Answer is D

Explanation

A. Sending the facility a copy of the client's complete medical record is not appropriate because it may contain sensitive information that is not relevant to the rehabilitative facility. Only the necessary information should be sent to ensure patient confidentiality and compliance with privacy regulations.

B. Avoiding the use of a fax cover sheet is not advisable as the cover sheet provides important information about the sender and the recipient, ensuring that the fax reaches the correct person and maintains confidentiality. It also helps in identifying the document if it gets misplaced.

C. Calling the facility to confirm the fax number after sending the client's information is not the best practice. The nurse should confirm the fax number before sending any information to prevent sending sensitive data to the wrong recipient.

D. Shredding extra copies of the client's records when they are no longer needed is a crucial step in maintaining patient confidentiality and preventing unauthorized access to sensitive information. Proper disposal of medical records is essential for compliance with privacy laws and regulations.

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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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