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Patient Data

Exhibits

The nurse reviews new data.

Which 5 nursing interventions are indicated for this client?

Apply sequential compression stockings when in bed.

Maintain strict bedrest for 12 hours after surgery.

Provide chilled beverages.

Change position frequently.

Encourage coughing and deep breathing.

Observe for signs and symptoms of dumping syndrome.

Keep client NPO

Maintain head at 45-degree angle.

Answer and Explanation

Correct Answer : A,D,E,F,H

Choice A reason: Applying sequential compression stockings when in bed is a recommended postoperative intervention for bariatric surgery patients. It helps prevent deep vein thrombosis (DVT) by promoting venous return and reducing venous stasis, which is particularly important in patients with obesity due to their increased risk for DVT.
Choice B reason: Maintaining strict bedrest for 12 hours after surgery is not typically recommended as it can increase the risk of complications such as DVT and pulmonary embolism. Early mobilization is generally encouraged to promote circulation and respiratory function.
Choice C reason: Providing chilled beverages is not a specific nursing intervention indicated in the immediate postoperative period for bariatric surgery patients. Fluid intake should be carefully monitored and regulated, but the temperature of the beverages is not a primary concern.
Choice D reason: Changing position frequently is an important postoperative intervention to prevent complications such as pressure ulcers and to promote lung expansion, especially in patients with obesity who are at higher risk for these issues.
Choice E reason: Encouraging coughing and deep breathing is essential after bariatric surgery to help clear the airways, prevent atelectasis, and improve oxygenation. This is particularly important for this patient who has a history of sleep apnea and reported diminished breath sounds postoperatively.
Choice F reason: Observing for signs and symptoms of dumping syndrome is relevant for bariatric surgery patients, as this syndrome can occur when food moves too quickly from the stomach to the small intestine. However, this is more of a long-term concern rather than an immediate postoperative intervention.
Choice G reason: Keeping the client NPO (nothing by mouth) is a common immediate postoperative order, but as the patient progresses, they will be started on a liquid diet and advanced as tolerated. Therefore, it is not a nursing intervention that would be indicated indefinitely.
Choice H reason: Maintaining the head at a 45-degree angle can help improve respiratory function by reducing pressure on the diaphragm, which is especially beneficial for patients with obesity and a history of sleep apnea, as in this case.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Choice A reason: Engaging in non-threatening conversations can help the client feel more comfortable and may encourage communication, which is crucial for clients who are withdrawn due to depression.

Choice B reason: Family visits can be supportive, but the client's withdrawal suggests a need for more direct intervention to encourage communication.

Choice C reason: Scheduling a conference with a social worker is important, but it is not the most immediate intervention for a withdrawn client.

Choice D reason: Group activities may be overwhelming for a client who is noncommunicative and may not be the most suitable initial approach.

A. Sloughing tissue around wound edges. B. Loss of sensation to the left lower extremity. C. Weeping serosanguineous fluid from wounds. D. Reporting increased pain and pressure. E. Change in the quality of the peripheral pulses.

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

Explanation

Choice A reason: Sloughing tissue around wound edges may require debridement but does not typically require immediate intervention unless there is a significant change in the wound's condition.

Choice B reason: Loss of sensation could indicate nerve damage or developing compartment syndrome, which is a medical emergency requiring immediate intervention to prevent permanent damage.

Choice C reason: Weeping serosanguineous fluid is expected in burn wounds and does not necessarily require immediate intervention unless there is a significant increase in output or other signs of infection.

Choice D reason: Increased pain and pressure are signs of potential compartment syndrome or infection, both of which require prompt assessment and possible intervention.

Choice E reason: A change in the quality of peripheral pulses may indicate vascular compromise, which requires immediate intervention to restore circulation and prevent tissue death.

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Patient Data Exhibits The nurse reviews new data. Which 5 nursing interventions are indicated for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse notes that a client with depression has been more withdrawn and noncommunicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?

Correct Answer is A

Explanation

When caring for a client with full-thickness burns to both lower extremities, which assessment findings warrant immediate intervention by the nurse? Select all that apply.

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

Explanation

Patient Data Exhibits After the physician orders the echocardiogram, the nurse educates the parents about the procedure. For each statement below, indicate whether it shows understanding or a lack of understanding by the parents.

The nurse is developing a plan of care for a client who reports chest pain on exertion and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?

After receiving a change of shift report for clients on a medical-surgical unit, which activity should the nurse delegate to the practical nurse (PN)?

The nurse places an opioid patch on the chest of a client with intractable pain who also has obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client?

Patient Data Exhibits The nurse reviews the post catheterization orders. Which two orders would the nurse question?

Patient Data Exhibits Which interventions are indicated to promote positive outcomes for the patient? Select all that apply.

A client with 50% full-thickness burns has received fluid resuscitation for the past 24 hours. Which assessment warrants immediate intervention by the nurse?

Which is the primary goal when planning nursing care for a client with degenerative joint disease (DJD)?

Patient Data

Exhibits

The nurse reviews new data.

Which 5 nursing interventions are indicated for this client?