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 B

Explanation

A. A rapid, irregular heart rate (e.g., atrial fibrillation) is common in mitral valve stenosis due to atrial enlargement but does not necessarily require immediate intervention unless it leads to severe symptoms like syncope or stroke.

B. Blood-tinged sputum could indicate pulmonary edema or pulmonary hypertension, both of which are serious complications of mitral valve stenosis. This finding warrants immediate intervention as it may signify acute heart failure or other critical complications requiring prompt treatment.

D. Swollen feet and ankles are common signs of fluid retention in heart failure, but they do not require immediate intervention compared to the potential complications of atrial fibrillation.

A. Weigh every morning. B. Limit fluid intake to 1,500 ml daily. C. Eat a high protein diet. D. Perform range of motion exercises.

Correct Answer is A

Explanation

A. Weigh every morning: Daily weighing helps monitor for fluid retention, which is important in managing heart failure. Sudden weight gain can indicate fluid accumulation and worsening heart failure symptoms, prompting the need for medical attention.
B. Limit fluid intake to 1,500 ml daily: While fluid restriction may be necessary for some
individuals with heart failure, the specific amount varies based on individual circumstances and should be determined by the healthcare provider. A blanket recommendation of 1,500 ml may not be appropriate for all patients.
C. Eat a high protein diet: While a balanced diet is important for overall health, there is no specific evidence to suggest that a high protein diet is essential for heart failure management. Dietary recommendations should be tailored to the individual's needs and comorbidities.
D. Perform range of motion exercises: While exercise is important for overall health, including for individuals with heart failure, range of motion exercises may not be the priority instruction for discharge teaching. Exercise recommendations should be individualized and may include aerobic and resistance training based on the client's condition and functional status.

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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

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