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 ["B","D","E"]

Explanation

A. Reddish streak proximal to the insertion site: This indicates phlebitis, not infiltration.
B. Skin is pale and taut: This is a sign of infiltration as fluid accumulates in the tissue around the IV site.
C. The vein is firm and cord-like: This is indicative of phlebitis or thrombophlebitis, not infiltration.
D. IV fluid leaking from insertion site: This is a clear sign of infiltration, where fluid leaks out of the vein into surrounding tissue.
E. Warmth at the insertion site: This can be a sign of infiltration or inflammation, depending on the context.

A. Tell the client he can no longer have any more pain medication B. Notify the prescribing physician C. Administer half the dose of morphine, 2 mg IV D. Administer 4 mg of morphine IV as ordered

Correct Answer is B

Explanation

A. Tell the client he can no longer have any more pain medication: This is not appropriate. The client’s severe pain needs to be managed, but the current vital signs suggest a need for careful evaluation before administration.
B. Notify the prescribing physician: This is the correct choice. The client's blood pressure and respiratory rate are significantly low, which could be exacerbated by morphine. The physician needs to be informed to reassess pain management and possibly adjust the treatment.
C. Administer half the dose of morphine, 2 mg IV: Given the client's low blood pressure and respiratory rate, any morphine administration could worsen these issues. Adjusting the dose without physician guidance is not appropriate.
D. Administer 4 mg of morphine IV as ordered: Administering the full dose without addressing the client’s low blood pressure and respiratory rate could lead to severe complications.

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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

Which of the following assessment findings should alert the nurse that a client's IV has infiltrated? (Select All That Apply)

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

Explanation

A client indicates to the nurse a pain level of 8 out of 10. The nurse notes the client has an order for morphine 4 mg IV Q 6 hr PRN for moderate to severe pain. The client's blood pressure is 80/54 mm Hg, respirations 10 breaths/min, and pulse 62 beats/min. Which action should the nurse take?

Correct Answer is B

Explanation

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