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Exhibits

Click to select the 5 most important nursing interventions for postoperative client care.

Encourage sitting up and ambulation

Monitor for bleeding once daily

Use incentive spirometer every 1 hour

Promote adequate hydration

Assess for sedation after pain medications

Complete neurologic assessment every 2 hours

Administer pain medication after activity

Answer and Explanation

Correct Answer : A,C,D,E,G

A.   Encouraging the client to sit up and ambulate helps prevent complications such as atelectasis and deep vein thrombosis by promoting lung expansion and blood circulation.
B.   While monitoring for bleeding is important, in most stable postoperative cases, continuous monitoring isn't necessary. Once daily checks are often sufficient.
C.   Regular use of the incentive spirometer helps prevent respiratory complications such as pneumonia by promoting deep breathing and lung expansion.
D.   Adequate hydration is essential for wound healing, preventing urinary retention, and maintaining overall physiological function. Encourage the client to drink fluids within their prescribed limits.
E.   Monitoring for sedation after administering pain medications is crucial to ensure the client's safety and prevent respiratory depression. Assess the client's level of consciousness, respiratory rate, and oxygen saturation regularly.
F.   Neurological assessments are usually not required this frequently unless there are specific concerns.
G.   Administering pain medication after activity helps manage postoperative pain effectively, enabling the client to participate in necessary activities such as ambulation and respiratory exercises. It's important to ensure that pain is adequately controlled to facilitate recovery and promote comfort.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["1.3"]

Explanation

To calculate the dosage of amoxicillin for the infant, first convert the weight from pounds to kilograms, knowing that 1 kilogram equals 2.2 pounds. The infant weighs 22 pounds, which is equivalent to 10 kilograms (22 lb / 2.2 lb/kg). The prescription is for 20 mg/kg/day, so the total daily dosage is 200 mg (10 kg * 20 mg/kg). This total daily dosage is divided into three doses, as it is to be administered every 8 hours, resulting in

66.7 mg per dose (200 mg / 3). The medication is supplied as 250 mg per 5 mL, so to find out how many mL per dose, set up a proportion: 250 mg is to 5 mL as 66.7 mg is to X mL. Solving for X gives us 1.334 mL (66.7 mg * 5 mL / 250 mg), which rounds to 1.3 mL when rounded to the nearest tenth.

A. incision dressing is dry and intact, and no bleeding is noted B. The client tolerated clear liquids post recovery and has advanced to a soft diet C. The client ambulated around the unit this morning and tolerated activity well D. Bowel sounds are present in all 4 quadrants, and per client report, she has passed flatus E. Pain is tolerated with analgesia PO

Correct Answer is ["A","B","C","D","E"]

Explanation

The incision dressing is dry and intact, with no bleeding noted: This indicates that the surgical site is healing well without any signs of infection or complications. A dry and intact dressing suggests that there is no active bleeding or wound drainage, which is a positive sign of wound healing.

The client has tolerated clear liquids post-recovery and has advanced to a soft diet: Progression from clear liquids to a soft diet indicates that the client's gastrointestinal function is returning to normal. This progression suggests that there are no immediate concerns regarding postoperative nausea, vomiting, or bowel obstruction.

The client has ambulated around the unit and tolerated activity well: Ambulation and tolerance of activity demonstrate the client's physical mobility and overall strength. Being able to move around the unit without difficulty suggests that the client is recovering well from the surgical procedure and is regaining strength and function.

Bowel sounds are present in all 4 quadrants, and the client has passed flatus: The presence of bowel sounds in all four quadrants indicates normal gastrointestinal motility and function. Passing flatus is another positive sign of gastrointestinal recovery, suggesting that the client's bowels are active and functioning properly post-surgery.

Pain is tolerated with analgesia orally: The client's ability to tolerate pain with oral analgesia indicates effective pain management and suggests that the surgical incision site is not causing significant discomfort or distress. Effective pain control is essential for postoperative comfort and can facilitate the client's recovery process.

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Exhibits Click to select the 5 most important nursing interventions for postoperative client care.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["1.3"]

Explanation

Correct Answer is ["A","B","C","D","E"]

Explanation

The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?

An older client is being admitted to a rehabilitation unit from a medical-surgical unit following a left hip replacement. When reviewing the client's prescribed medications, which intervention should the nurse implement first?

A client is admitted to a medical unit with a diagnosis of gastritis and chronic heavy alcohol abuse. Which medication should the nurse administer to prevent the development of Wernicke's syndrome?

The nurse initiates the procedure to remove a client's peripherally inserted central catheter (PICC) when a code blue is called for another client in the unit who collapsed in the hallway while ambulating with the unlicensed assistive personnel (UAP). Which action should the nurse take?

The nurse is caring for an immobile client after spinal surgery. Which action is most important for the nurse to take to prevent postoperative complications?

Patient Data Exhibits The healthcare provider has assessed the client and completes initial prescriptions. Which three interventions should the nurse prioritize for this client?

Exhibits Click to indicate which interventions the nurse would include in the plan of care to support the expected outcomes of adequate epidural anesthesia on the mother and the fetus. Each column must have a least one but may have more than response option selected

The nurse is performing a routine assessment of an IV site for a client receiving both IV fluids and medications through the line. The client reports tenderness when the nurse touches the arm above the site. Which finding should the nurse expect which will require immediate intervention?

Exhibits

Click to select the 5 most important nursing interventions for postoperative client care.