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 ["B","C","E"]
Explanation
A. Pale, yellow urine: While pale yellow urine can be a symptom of a UTI, it is not specific enough and can be caused by other factors like dehydration or certain medications. Therefore, it is not a reliable indicator of a UTI in this case.
B. Cloudy urine: Cloudy urine is a more specific symptom of a UTI, as it can indicate the presence of white blood cells or bacteria in the urine. This finding, along with other symptoms, suggests a possible UTI.
C. Suprapubic pain: Suprapubic pain, which is pain felt above the pubic bone in the lower abdomen, is a common symptom of bladder infections, including UTIs. This finding is highly suggestive of a UTI in this client.
D. Temperature of 38.2 C (100.7 F): Although fever can be a symptom of a UTI, it is not always present and can be caused by other infections or conditions. Therefore, a single elevated temperature, without other supporting symptoms, is not conclusive for a UTI diagnosis.
E. Constant urge to urinate (dysuria): Dysuria, or a frequent and urgent need to urinate, is another common symptom of UTIs. This finding, along with cloudy urine and suprapubic pain, further strengthens the suspicion of a UTI in this client.
Correct Answer is C
Explanation
Choice A rationale:
While it's true that gastrointestinal peristalsis may be slowed after surgery, this is not the primary reason for administering a cleansing enema before colon surgery.
The main goal of the enema is to evacuate stool from the colon, ensuring a clear and unobstructed surgical field. This helps to:
Reduce the risk of infection
Facilitate better visualization of the colon during surgery
Minimize the potential for complications
Choice B rationale:
Cleansing enemas are not administered solely based on patient request.
They are prescribed for specific medical reasons, such as preparing for colon surgery or certain diagnostic procedures. Patient preference may be considered, but it's not the determining factor.
Choice C rationale:
While decreased gas and discomfort post-operatively can be a potential benefit of a cleansing enema, it's not the primary reason for its use before colon surgery.
The primary goal, as mentioned earlier, is to clear the colon for a safe and effective surgical procedure. However, reduced gas and discomfort can contribute to a smoother post-operative recovery.
Choice D rationale:
Multiple cleansing enemas are not routinely given to all surgical patients.
The decision to administer an enema is based on the specific type of surgery, the patient's condition, and other factors. In some cases, a single enema may be sufficient, while others may require more than one.
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