The nurse is caring for an older adult client who is admitted to the surgical unit following a partial gastrectomy. In addition to frequent position changes, which postoperative intervention is most beneficial for the nurse to perform in preventing respiratory complications?

Promote full diaphragmatic excursion by massaging the back.

Note areas of atelectasis on the daily chest x-rays.

Assist to a chair the day after surgery when the condition is stable.

Provide ice or oral liquids when the client passes flatus.

Answer and Explanation

The Correct Answer is A

A.   Promoting full diaphragmatic excursion by massaging the back helps to facilitate deep breathing and lung expansion, which is essential for preventing respiratory complications such as atelectasis and pneumonia after surgery.
B.   Noting areas of atelectasis on daily chest x-rays is important for assessing respiratory status, but it is a monitoring intervention rather than a preventive intervention.
C.   Assisting the client to a chair the day after surgery when the condition is stable promotes early mobility and prevents complications such as deep vein thrombosis, but it may not directly
address respiratory complications.
D.   Providing ice or oral liquids when the client passes flatus may be part of the postoperative care plan, but it does not directly address respiratory complications. It's more related to bowel function and hydration status.

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Correct Answer is A

Explanation

A. Administer four 81 mg aspirin tablets providing instructions to chew before swallowing: Aspirin helps inhibit platelet aggregation and is commonly administered to clients with suspected acute coronary syndrome to reduce the risk of myocardial infarction.
B. Evaluate upper and lower extremities for perfusion, pulse volume, and pitting edema: While assessing extremities is important, administering aspirin takes priority in clients with suspected acute coronary syndrome.
C. Place an indwelling urinary catheter and institute strict intake and output measurements: This intervention is not indicated in the immediate management of a client with suspected acute
coronary syndrome.
D. Secure client consent for coronary angiography and percutaneous coronary intervention: While these procedures may be necessary later, the immediate priority is to administer aspirin and stabilize the client's condition.

A. Remove dentures or other oral appliance. B. Elevate the head of the bed to a 45-degree angle. C. Apply the client's positive airway pressure device. D. Lift and lock the side rails in place.

Correct Answer is C

Explanation

A. Remove dentures or other oral appliance: While important for airway management, it is not specifically related to the client's condition of sleep apnea.
B. Elevate the head of the bed to a 45-degree angle: This intervention can help reduce the risk of aspiration but is not specific to managing sleep apnea.
C. Apply the client's positive airway pressure device: Clients with obstructive sleep apnea often use positive airway pressure devices to maintain airway patency during sleep, so ensuring its application is crucial.
D. Lift and lock the side rails in place: This intervention is important for client safety but does not directly address the client's sleep apnea.

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The nurse is caring for an older adult client who is admitted to the surgical unit following a partial gastrectomy. In addition to frequent position changes, which postoperative intervention is most beneficial for the nurse to perform in preventing respiratory complications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next?

Correct Answer is A

Explanation

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?

Correct Answer is C

Explanation

A client with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next?

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