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Exhibits

The nurse is caring for the client the morning after her surgery.

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. Early ambulation helps prevent complications such as atelectasis, pneumonia, and deep vein thrombosis (DVT). It also promotes intestinal motility.
B. Monitoring for bleeding should be more frequent, especially in the immediate postoperative period, rather than just once daily.
C. This helps prevent respiratory complications such as atelectasis and promotes lung expansion.
D. Adequate hydration is essential to maintain fluid balance, promote healing, and prevent complications such as urinary tract infections and constipation.
E. Monitoring for sedation is crucial to ensure that pain medications are not causing excessive drowsiness, which could impair the client's ability to participate in activities such as ambulation and use of the incentive spirometer.
F. While assessing neurological status is important, frequent neurological assessments are more relevant for clients with neurological conditions or concerns. In this case, routine assessments should be sufficient unless the client has specific neurological symptoms.
G. Administering pain medication after activity helps manage pain more effectively and encourages the client to engage in necessary postoperative activities.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Establish a structured routine for the client to follow. Establishing a consistent routine is essential to help clients with depression manage their symptoms and create a sense of structure and control. It can also help them feel more motivated to engage in activities.
B. Arrange a meeting with the family to discuss the client's situation. While family involvement is important, it is not the first priority. Immediate care interventions are needed to address the client’s current needs.
C. Assess the client's ability to communicate with the other staff members. While communication is important, the priority is to address the client’s physical and emotional needs by establishing a routine.
D. Administer the client's antidepressant medication as prescribed. Medication management is crucial, but the first step is to engage the client in a structured routine to help them begin functioning.

A. Prepare to administer warfarin B. Review last partial thromboplastin time (PTT) results. C. Assess characteristics of pain. D. Monitor stools for presence of blood E. Auscultate bowel sounds in all quadrants.

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

Explanation

A. Warfarin is not administered in this situation unless directed by a provider; the priority is addressing possible bleeding.
B. Reviewing the last PTT results is important to assess the effectiveness of heparin and monitor for potential bleeding complications.
C. Assessing the characteristics of pain can help determine if the client is experiencing gastrointestinal bleeding, which is a concern with heparin therapy.
D. Monitoring for blood in the stool is crucial, as tarry stools indicate possible gastrointestinal bleeding, a known complication of anticoagulation therapy.
E. Auscultating bowel sounds is important but does not directly address the potential complication of gastrointestinal bleeding, which is the priority in this situation.

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Exhibits The nurse is caring for the client the morning after her surgery. Click to select the 5 most important nursing interventions for postoperative client care.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first?

Correct Answer is A

Explanation

A client with deep vein thrombosis (DVT) is receiving a continuous heparin IV infusion. The client now has tarry, black diarrhea and reports abdominal pain. Which actions should the nurse implement? Select all that apply.

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

Explanation

While caring for a toddler receiving oxygen via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement?

A client with hemorrhoids asks for information about a high fiber diet. Which breakfast menu item(s) should the nurse suggest? Select all that apply.

A client is admitted during the acute phase of a stroke. The nurse observes that the client is restless and unable to follow instructions. Which instruction(s) should the nurse provide the unlicensed assistive personnel (UAP) who is assisting with the care of the client? Select all that apply.

A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

A female client is taking alendronate, a bisphosphonate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?

Which client should the charge nurse on the oncology unit assign to a registered nurse (RN), rather than a practical nurse (PN)?

Exhibits The nurse suspects elder mistreatment. Click to indicate if the listed manifestation of abuse is consistent with physical abuse, abandonment, or neglect. Each row must have only one response option selected.

Exhibits

The nurse is caring for the client the morning after her surgery.

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