The practical nurse (PN) is assigned to care for a client who underwent fixation of a mandible fracture. Upon entering the client's room, the PN should confirm the presence of which item(s) in the client's room? Select all that apply.

Choice A reason: Positioning the client supine and flat is not specifically aimed at preventing phantom pain. Phantom pain is a common issue after amputations, and its management typically involves medications, therapies, and psychological support rather than positioning. Keeping the client supine and flat may not address the immediate concerns of bleeding and swelling, which are critical in the initial postoperative period.
Choice B reason: Turning the client prone every 2 hours to prevent hip flexion contractures is an important intervention to prevent contractures after a below-the-knee amputation. However, this is not the immediate priority immediately following surgery. The primary concern in the immediate postoperative period is to manage bleeding, swelling, and ensuring proper healing of the residual limb.
Choice C reason: Elevating the residual limb on pillows to prevent bleeding and swelling is the most crucial intervention immediately after a below-the-knee amputation. Elevation helps reduce edema, promote venous return, and minimize the risk of postoperative bleeding. Proper elevation also supports the healing process of the surgical site. This intervention addresses the immediate needs of the client and helps prevent complications in the critical early stages after surgery.
Choice D reason: Positioning the residual limb below the heart to promote healing for prosthetic fitting is not recommended in the immediate postoperative period. Keeping the limb elevated is more beneficial to reduce swelling and manage bleeding. The focus in the immediate phase is to ensure proper healing and prevent complications, with considerations for prosthetic fitting coming later in the rehabilitation process.

Choice A reason: Demonstrating the use of an incentive spirometer is a valuable intervention for encouraging deep breathing and preventing atelectasis. However, in the context of a client with absent breath sounds on one side, the priority is to monitor for signs of respiratory distress or complications such as a pneumothorax. While using an incentive spirometer may be beneficial in other scenarios, it is not the immediate priority in this case.
Choice B reason: Monitoring the client for increasing respiratory distress is the most critical action to take. The absence of breath sounds on the left side could indicate a serious complication such as a pneumothorax, hemothorax, or other issues that can compromise respiratory function. By closely monitoring the client, the practical nurse can detect signs of worsening condition, such as increased work of breathing, cyanosis, or changes in vital signs, and provide timely intervention or support while awaiting the healthcare provider's arrival.
Choice C reason: Administering a PRN dose of a diuretic medication is not appropriate in this context. Diuretics are used to manage fluid balance and treat conditions such as heart failure or hypertension but are not relevant for addressing the immediate concern of absent breath sounds and potential respiratory distress. The focus should remain on monitoring the client's respiratory status and ensuring appropriate interventions are available if needed.
Choice D reason: Encouraging the client to use pursed-lip breathing can be beneficial for clients experiencing shortness of breath or for managing chronic obstructive pulmonary disease (COPD). However, in the case of absent breath sounds on one side, it is more important to monitor for signs of respiratory compromise and ensure the client receives prompt medical evaluation and intervention. Pursed-lip breathing is not the immediate priority in this scenario.