When providing care for a client on the first postoperative day following an appendectomy, which intervention should the practical nurse implement?

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.

Choice A reason: Assessing urine for ketones is an important step in diagnosing diabetic ketoacidosis (DKA), a serious complication of diabetes. Ketones are produced when the body breaks down fat for energy due to a lack of insulin. High levels of ketones in the urine can indicate DKA. However, while this is a necessary assessment, it is not the immediate priority. The most urgent action is to measure the blood glucose to determine if hyperglycemia is present, which is a key indicator of DKA.
Choice B reason: Auscultating breath sounds is an important assessment to evaluate the client's respiratory status. Deep, rapid respirations (Kussmaul respirations) are often associated with DKA as the body attempts to compensate for metabolic acidosis. While auscultating breath sounds is valuable, it is not the first action to take. The primary concern is to confirm hyperglycemia, which is a critical step in diagnosing and managing DKA.
Choice C reason: Elevating the head of the bed can help improve the client's comfort and respiratory function, especially if they are experiencing difficulty breathing. However, this action does not directly address the underlying issue of hyperglycemia and potential DKA. While it can be part of supportive care, the immediate priority is to measure the blood glucose levels to assess the severity of the condition and initiate appropriate treatment.
Choice D reason: Measuring the blood glucose is the most critical and immediate action. Deep, rapid respirations and a fruity breath odor are classic signs of DKA, a life-threatening condition that requires prompt diagnosis and treatment. By measuring the blood glucose, the practical nurse can confirm hyperglycemia and initiate interventions to manage blood sugar levels, such as insulin administration and fluid replacement. Early detection and treatment are essential to prevent complications and stabilize the client’s condition.