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 indicates infiltration as fluid accumulates in the surrounding tissue, causing the skin to appear pale and tight.
C. The vein is firm and cord-like: This is typically a sign of phlebitis or thrombophlebitis, not infiltration.
D. IV fluid leaking from insertion site: This is a sign of infiltration where fluid has leaked out of the vein into the surrounding tissue.
E. Warmth at the insertion site: This can indicate infiltration or inflammation, depending on other symptoms present.

A. "Maybe you are more depressed than you realize. Would you like to talk about it?" B. "Depression is often a factor in pain. Treating the depression helps treat the pain." C. "Why don't you try it for a while, and if you don't feel better, you can ask your doctor if you can stop it?" D. "Antidepressants are sometimes used to manage the type of nerve pain you are experiencing."

Correct Answer is D

Explanation

A. "Maybe you are more depressed than you realize. Would you like to talk about it?": This response may dismiss the client's concerns and assumes depression without explaining the rationale for the medication.
B. "Depression is often a factor in pain. Treating the depression helps treat the pain.": While this may be true, it might not address the specific rationale for the antidepressant in managing nerve pain.
C. "Why don't you try it for a while, and if you don't feel better, you can ask your doctor if you can stop it?": This response lacks an explanation and may not address the client’s concerns about why the medication was prescribed.
D. "Antidepressants are sometimes used to manage the type of nerve pain you are experiencing.": This is the correct choice. It directly addresses the use of antidepressants for managing neuropathic pain, which can be effective even in the absence of depression.

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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 with peripheral neuropathy states, "I don't know why the doctor put me on an antidepressant. I am not depressed!" Which response by the nurse is best?

Correct Answer is D

Explanation

After having an intravenous (IV) line in place for 72 hours, a client complains of tenderness, burning, and swelling. Assessment of the IV site reveals a cord-like vein and a reddened streak. The nurse identifies that these findings indicate what complication?

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?

A client has a serum calcium level of 12.8 mg/dL. Which medication will likely be prescribed for this client?

An unresponsive client was brought to the emergency room and had an arterial blood gas drawn. Ten minutes later, the laboratory calls with the following results: PaO2 74%, pH 7.22, PaCO2 85 mm Hg, and HCO3 23 mEq/L. The nurse interprets the results as indicating which imbalance?

A client is being transferred to the medical-surgical unit from the PACU after receiving general anesthesia for a procedure. Which of the following actions is the priority for the nurse when the client arrives on the unit?

A nurse working in the post-anesthesia care unit (PACU) is caring for a post-operative client that just had pelvic surgery. The nurse anticipates assessing for what post-operative complaint related to spinal anesthesia?

A nurse is providing care for a hospitalized client admitted with dehydration. Which assessment finding indicates interventions have been effective?

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?