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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.


View Related questions

Correct Answer is B

Explanation

A. Light bleeding from the stoma can be normal in the early postoperative period, but it should be monitored.

B. A dark-colored stoma can indicate ischemia or compromised blood supply, which is a critical finding that requires immediate reporting to the provider.

C. Slight protrusion of the stoma is typically expected and not a cause for concern.

D. Small amounts of liquid stool from the stoma are normal in the immediate postoperative period and do not need to be reported.

Correct Answer is B

Explanation

A. While it is important to restrict access to medical records, it is not solely the risk manager's role to give permission; the policy should be followed regarding patient information access.

B. Reminding the nurse that only those directly involved in the client's care should access their medical record upholds confidentiality and patient privacy standards.

C. Completing an incident report is a more formal step and might be warranted later, but initially addressing the behavior directly is more appropriate.

D. Contacting security would be an extreme response; addressing the situation with the nurse first is typically the best course of action.