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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"C"}}
Explanation
Bruises in various stages of healing: This often indicates physical abuse, as it suggests trauma or injury from external force.
Over-sedation: This could be indicative of physical abuse if it is intentional or misuse of medications.
Depression or withdrawn behavior: These can be signs of neglect, as they may result from a lack of emotional support or social interaction.
Leaving an older adult in a public space: This is a clear indicator of abandonment, as it shows neglect of the individual's safety and well-being.
Untreated pressure injuries: These are signs of neglect, reflecting a failure to provide adequate care and prevent injuries.
Poor personal hygiene: Often a result of neglect, indicating a lack of attention to the individual's basic needs and self-care.
Correct Answer is B
Explanation
A. Recommending that family return may not be feasible or realistic for the client.
B. A case management evaluation can help assess the home environment and identify potential resources or support services, such as home health care, that can assist the client with caregiving duties.
C. Respite care facilities may not be the best solution if the client's husband does not require extended care, and home-based support could be more appropriate.
D. Hiring a private nurse could be expensive and may not be necessary if other resources are available through case management or home health services.
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