To promote effective coughing, deep breathing, and ambulation in the postoperative client, what nursing action is most important?

Provide adequate and regular pain medication

Teach the client pursed-lip breathing

Encourage continued bedrest and ensure quality sleep

Use an incentive spirometer to motivate the client

Answer and Explanation

The Correct Answer is A

A. Provide adequate and regular pain medication: Effective pain management is crucial for postoperative clients to perform deep breathing, coughing, and ambulation comfortably and effectively. Pain relief enables better participation in these activities.
B. Teach the client pursed-lip breathing: While pursed-lip breathing is beneficial for some respiratory conditions, it is less directly related to promoting postoperative activities compared to pain management.
C. Encourage continued bedrest and ensure quality sleep: Encouraging bedrest may hinder postoperative recovery; instead, ambulation and movement are important for recovery.
D. Use an incentive spirometer to motivate the client: Although an incentive spirometer helps with deep breathing, it is less effective without proper pain management to support these activities.

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Correct Answer is C

Explanation

A. Capillary refill and depth of peripheral edema: While these assessments are important for evaluating peripheral circulation and fluid status, they are not as immediately critical given the client's new onset of confusion and respiratory symptoms.
B. Abdominal sounds and obtain a BNP level: Assessing abdominal sounds and BNP (B-type natriuretic peptide) levels is useful for diagnosing heart failure exacerbations but is secondary to addressing the client's acute confusion and potential electrolyte imbalances.
C. Neurological status and obtain electrolyte levels: This is the correct choice. New onset confusion can be indicative of electrolyte imbalances or acute exacerbations related to heart failure. Monitoring neurological status and electrolyte levels is crucial to address potential causes of confusion and ensure proper treatment.
D. Skin turgor and measure intake & output (I&O): While skin turgor and I&O are relevant for assessing fluid status, the priority should be addressing the acute change in mental status and potential underlying causes such as electrolyte imbalances.

A. Flush the IV site with normal saline, then restart the IV potassium therapy B. Discontinue the IV and restart in another site C. Flush the IV site with heparin D. Stop the IV site and check for blood return

Correct Answer is B

Explanation

A. Flush the IV site with normal saline, then restart the IV potassium therapy: Flushing and restarting the infusion at the same site is not appropriate if there is redness and swelling, as these are signs of possible phlebitis or infiltration.
B. Discontinue the IV and restart in another site: This is the correct choice. Given the erythema and edema, which indicate possible complications like phlebitis or infiltration, the IV should be discontinued and restarted in a new site to prevent further complications.
C. Flush the IV site with heparin: This is not appropriate for erythema and edema and could exacerbate the problem. Heparin is used to maintain patency of IV lines, not to treat complications.
D. Stop the IV site and check for blood return: While checking for blood return is a good practice to assess for patency, the primary action should be to discontinue the IV and start a new one due to the complications at the site.

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To promote effective coughing, deep breathing, and ambulation in the postoperative client, what nursing action is most important?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client has been receiving IV potassium therapy. Upon further assessment, the nurse notes the site has become erythematous and edematous. Which action by the nurse is most appropriate?

Correct Answer is B

Explanation

A nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL. Which condition most likely caused this serum phosphorus level?

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A nurse is monitoring a client who is receiving IV fluid. Which clinical findings indicate that the client has fluid overload?

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