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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. While it's important to know about peripheral pulses and mobility, this is not as critical immediately post-op.
B. A history of vomiting is relevant but not immediately actionable for the current post-op care.
C. Dry mouth is a common and manageable symptom post-op, but not immediately critical.
D. A soft abdomen, absent bowel sounds, and no bleeding on dressing provide essential information on the client's current post-op status and potential complications, making it the most important information to confirm.
Correct Answer is A
Explanation
A. Bringing a sterile chest drainage unit from central supply is a task that does not require clinical judgment and is suitable for a UAP.
B. Calling the pharmacy involves understanding and communication about medications, which should be handled by licensed staff.
C. Observing a client's gait to determine the need for assistance involves assessment and clinical judgment, which is beyond the UAP's scope.
D. Evaluating a client's urinary catheter for proper drainage requires assessment skills that are within the scope of licensed nurses.
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