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  1. A nurse is assisting with the care of a client.

Nurses' Notes

0800:

Client is 1 day postoperative following an open appendectomy. Client reports nausea and continued pain as 4 on a scale of 0 to 10. No emesis noted at this time, although client is reluctant to eat. Bowel sounds hypoactive. Lung sounds diminished in upper lobes with noted crackles in lower lobes. Respirations shallow, even, and unlabored. Client declined ambulation or incentive spirometry at this time. Incision to right lower abdomen intact, slightly reddened and without drainage. Ondansetron administered for nausea.

1000:

Client reports pain as 7 on scale of 0 to 10 with pain localized to right lower quadrant and without radiation. Reports pain is constant and dull with sharp pains experienced with movement. Morphine 2 mg IV bolus administered by RN.

Which of the following actions should the nurse take to promote the client's respiratory status? Select all that apply.

A.

Encourage the client to splint the abdomen when coughing.

B.

Administer acetaminophen.

C.

Administer ondansetron.

D.

Remind the client to use the incentive spirometer five times per hr.

E.

Encourage the client to cough and deep breathe.

F.

Plan to ambulate the client 30 min after the next analgesic is administered.

Question Solution

Correct Answer : A,D,E,F

A. Splinting the abdomen helps reduce pain during coughing, making it easier for the client to take deep breaths and effectively clear secretions. This is particularly important after abdominal surgery to minimize discomfort and promote effective coughing.

 

B. While acetaminophen can help with pain relief, it does not directly address the respiratory status of the client. Therefore, it is not a priority action in this context.

 

C. Ondansetron is effective for managing nausea, but it does not contribute to improving respiratory status directly. It is necessary for comfort, but it is not an action that promotes respiratory function.

 

D. The incentive spirometer is a valuable tool for encouraging deep breathing, which helps expand the lungs, improve ventilation, and prevent atelectasis (lung collapse). Regular use of the spirometer is crucial, especially in postoperative clients with decreased mobility.

 

E. Coughing and deep breathing are essential practices to prevent respiratory complications. They help clear secretions and promote lung expansion, which can improve oxygenation and respiratory function.

 

F. Ambulation is important for improving respiratory status by promoting lung expansion and circulation. It also aids in preventing complications such as deep vein thrombosis (DVT) and pneumonia. Planning ambulation after administering analgesics ensures that the client is more comfortable and able to participate in this activity.


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Correct Answer is B

Explanation

A. A 10-mL syringe is typically too small for effective wound irrigation; a larger syringe (30 mL or more) is usually recommended to provide adequate pressure and volume for cleansing.

B. Holding the syringe tip 2.5 cm (1 in) above the wound ensures that the irrigation solution is delivered effectively without directly contaminating the wound.

C. Cotton balls should not be used for wound cleansing, as they can leave fibers behind; gauze pads or sterile swabs are more appropriate.

D. The wound bed should not be dried with gauze; instead, it should remain moist or be covered with appropriate dressings to promote healing.

Correct Answer is C

Explanation

A. Focused breathing is part of relaxation techniques but is not the same as guided imagery.

B. Noticing muscle tension is part of progressive muscle relaxation, not guided imagery.

C. Guided imagery involves visualizing a pleasant or calming scene (such as a farm) to distract from pain and promote relaxation.

D. Listening to music can be helpful for relaxation but is a separate strategy from guided imagery.