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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Help her arrange transferring her partner to an assisted living facility: While respite care may indirectly contribute to exploring long-term care options like assisted living, its primary purpose is to provide temporary relief to caregivers, rather than facilitating permanent transfers.
B. Provide volunteers who will run errands for her: While volunteer services may be part of some respite care programs, the primary benefit of respite care is to give the caregiver a
temporary break from caregiving duties, rather than solely focusing on running errands.
C. Allow her to take time off from attending to her partner: This is the correct answer. Respite care provides the caregiver with the opportunity to take a temporary break from caregiving responsibilities, allowing them to rest, rejuvenate, and attend to their own needs.
D. Send a clinician to assess the safety of leaving her partner alone: While safety assessments may be important, especially for individuals with cognitive impairment, respite care primarily focuses on providing temporary relief to caregivers rather than conducting safety assessments.
Correct Answer is D
Explanation
A. The nurse is responsible for disclosing the expected outcomes of the proposed treatment is incorrect. It is the provider’s responsibility to explain the procedure, risks, benefits, and alternatives, not the nurse's. The nurse's role is to reinforce the information provided by the provider.
B. Consent can be verbal or written is incorrect. While some minor procedures may involve implied or verbal consent, informed consent for major procedures, surgeries, or treatments must be written and signed by the client.
C. Nurses rely on consent to perform interventions is incorrect. While consent is important, routine nursing interventions (such as administering medications or checking vital signs) are covered under general consent given at admission. Informed consent is specifically required for invasive or high-risk procedures.
D. The nurse's signature indicates they witnessed the client's signature is correct. The nurse's role in informed consent is to witness the client signing the document and ensure they signed voluntarily, without coercion, and with full understanding of the procedure as explained by the provider.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
