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. Crush the medication and administer it through the tube: Crushing sustained-release medications can alter their release mechanism, leading to potential overdose or ineffective treatment. Sustained-release formulations should not be crushed.
B. Provide the medication orally for the client to swallow: This option is not appropriate because the client has a gastrostomy tube, and oral administration is not suitable for this route.
C. Ask the healthcare provider to prescribe the medication as an elixir for tube administration: This is the correct approach as it ensures the medication is in a form suitable for administration through the gastrostomy tube without altering its release properties.
D. Dissolve the medication in water and administer it through the tube: Dissolving sustained-release tablets is not recommended as it may compromise the medication's intended release mechanism.

A. Absence of the client's gag reflex B. The client has a respiratory rate of eight (8) C. Loss of sensation at the 5th lumbar space D. The blood pressure is within 20% of the client's baseline

Correct Answer is B

Explanation

A. Absence of the client's gag reflex: This finding is not typically related to spinal anesthesia complications. The gag reflex is more pertinent to general anesthesia and its effects on the brainstem.
B. The client has a respiratory rate of eight (8): This is the correct choice. A low respiratory rate (bradypnea) could indicate significant complications from spinal anesthesia, such as respiratory depression, especially if the anesthesia affects the muscles involved in respiration.
C. Loss of sensation at the 5th lumbar space: This could be a normal effect of spinal anesthesia if the level of anesthesia was intended to cover this area, but it does not necessarily indicate a complication.
D. The blood pressure is within 20% of the client's baseline: A slight change in blood pressure within this range is generally not considered a severe complication of spinal anesthesia. Significant hypotension or instability would be more concerning.

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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

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