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A nurse is assisting with the care of a client.
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.
Encourage the client to splint the abdomen when coughing.
Administer acetaminophen.
Administer ondansetron.
Remind the client to use the incentive spirometer five times per hr.
Encourage the client to cough and deep breathe.
Plan to ambulate the client 30 min after the next analgesic is administered.
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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View Related questions
Correct Answer is A
Explanation
A. Tightening the abdominal muscles helps to stabilize the core and reduce strain on the back while lifting, thereby decreasing the risk of injury. This action supports proper body mechanics.
B. Bending at the waist places undue strain on the back muscles and increases the likelihood of injury. Proper lifting technique involves bending at the knees.
C. Keeping the legs straight leads to improper body mechanics, which can strain the back and lead to injury. Bending at the knees is recommended.
D. Holding the object away from the body increases stress on the back muscles. Holding it close to the body helps to distribute the weight evenly.
Correct Answer is A
Explanation
A. Disclosing information to a medical interpreter is permissible for providing direct care to the client and does not require written consent. This action is part of necessary communication to ensure proper understanding of care.
B. Sharing information with a family member without the client’s consent is a breach of confidentiality, except in specific situations allowed by law.
C. Disclosing information to an employer for pre-employment screening would require explicit client consent due to confidentiality laws.
D. Providing information to an insurance agency for a life insurance policy would also require the client’s consent.