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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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Free Nursing Study Resources

Correct Answer is C

Explanation

A. This describes a normal spine alignment.

B. This describes kyphosis, not lordosis.

C. Lordosis is an excessive inward curvature of the lumbar spine, often called "swayback."
D. This describes scoliosis, not lordosis.

A. Keep head of bed raised 45 degrees. B. Monitor blood glucose level. C. Maintain strict intake and output. D. Assess warmth of extremities.

Correct Answer is B

Explanation

A. Elevating the head of the bed can help improve oxygenation but is not directly related to managing sepsis.
B. Monitoring blood glucose levels is crucial in sepsis management as hyperglycemia can exacerbate the inflammatory response.
C. While intake and output monitoring is important, it is not the priority in the early management of sepsis.
D. Assessing warmth of extremities is important but not the most critical intervention in managing sepsis.

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

Nursing Test Bank

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Exhibits

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