Based on this finding, which postoperative intervention would be included on the nursing plan of care?
Perform sterile dressing changes each morning.
Administer pain medications as needed.
Conduct a head-to-toe assessment each shift.
Monitor respirations and breath sounds.
The Correct Answer is D
Choice A rationale:
Sterile dressing changes each morning are not directly related to the finding in question. While maintaining sterile dressings is important for postoperative wound care, it's not the primary intervention based on the specific finding you've presented. I'll need more information about the finding to determine the most appropriate rationale for this choice.
Choice B rationale:
Administering pain medications as needed is a common postoperative intervention, but it's not always the most crucial one depending on the patient's condition and the specific finding. It's important to assess the patient's pain level and administer medications accordingly, but pain management shouldn't overshadow other essential interventions.
Choice C rationale:
Conducting a head-to-toe assessment each shift is a comprehensive assessment, but it may not be necessary for every postoperative patient in every situation. The frequency and extent of assessments should be tailored to the patient's individual needs and the specific findings.
Choice D rationale:
Monitoring respirations and breath sounds is often the most critical postoperative intervention, as it allows for early detection of respiratory complications such as pneumonia, atelectasis, or pulmonary embolism. These complications can be life threatening, so prompt identification and intervention are essential.
Specific reasons why monitoring respirations and breath sounds is essential based on the finding (which you haven't provided) could include:
Evidence of respiratory distress or compromise
Changes in breathing patterns or sounds
Decreased oxygen saturation levels
Increased work of breathing
Risk factors for respiratory complications (e.g., type of surgery, underlying lung disease)
I'm ready to provide a more comprehensive rationale for each choice once you share the specific finding that prompted this question.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Circular turns involve wrapping the bandage around the limb in a continuous circle, with each layer overlapping the previous one. While this technique is effective for securing dressings on cylindrical body parts like the arm or thigh, it's not ideal for joints like the ankle. Circular turns can constrict movement and potentially impair circulation, especially if applied too tightly. Additionally, they don't provide adequate compression for wounds that require it.
Choice B rationale:
Figure-of-eight turns create a cross-over pattern around the joint, resembling the number 8. This technique offers better flexibility and movement compared to circular turns, but it's still not the most appropriate for the ankle. The cross-over pattern can create uneven pressure points and potentially lead to discomfort or even skin irritation. Moreover, it might not provide sufficient compression for wound management.
Choice C rationale:
Spiral turns involve wrapping the bandage diagonally, ascending or descending the limb, with each layer overlapping the previous one by about half its width. This technique is considered the most suitable for bandaging joints like the ankle for several reasons:
Conforms to Joint Contours: Spiral turns naturally mold to the shape of the ankle, providing even pressure distribution and avoiding constriction points. This ensures comfort and maintains proper blood flow.
Allows for Movement: The diagonal pattern accommodates the natural flexion and extension of the ankle joint, allowing for greater mobility without compromising bandage integrity.
Provides Effective Compression: Spiral turns can be applied with varying degrees of compression to suit the needs of the wound and surrounding tissue. This can help control bleeding, reduce swelling, and promote healing.
Easy to Apply and Adjust: Spiral turns are relatively straightforward to apply and can be easily adjusted if needed, making them adaptable to different wound sizes and patient needs.
Choice D rationale:
Recurrent bandaging involves wrapping the bandage back and forth over the same area multiple times, creating a thicker layer. This technique is primarily used for stumps or areas requiring significant padding and absorption. It's not typically used for bandaging joints like the ankle, as it can create excessive bulk and potentially restrict movement.
Correct Answer is C
Explanation
Choice A rationale:
It is inappropriate and dismissive to tell a client who has experienced a traumatic loss that they should be grateful to be alive. This statement invalidates the client's feelings of grief and loss, and it can hinder the coping process.
It is important for nurses to recognize that grief is a normal and healthy response to loss.
Telling a client to be grateful can imply that their feelings of grief are not valid or that they are not coping appropriately. This can lead to feelings of guilt, shame, and isolation, which can further complicate the grieving process.
Choice B rationale:
It is incorrect to label a client's grief as an abnormal or inappropriate response. Grief is a universal human experience, and there is no right or wrong way to grieve.
Each individual grieves in their own way and at their own pace.
Some people may express their grief openly, while others may grieve more privately.
It is important for nurses to respect the client's individual grieving process and to provide support without judgment. Choice C rationale:
It is important for nurses to recognize that grief is a normal and healthy response to loss.
It is a natural process that allows individuals to come to terms with their loss and to adjust to life without their loved one or without a part of their body.
Experiencing grief does not mean that there is something wrong with the client.
In fact, it is a sign that the client is beginning to process their loss.
Choice D rationale:
While tissue healing is important, it is not the only factor that will help the client to adapt to their loss. The client will also need to address the emotional and psychological aspects of their loss.
This may involve talking about their feelings, seeking support from others, and finding ways to cope with their grief.
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