a nurse is developing a plan of care for a client who is postoperative which of the following interventions should the nurse include in the plan to pr a nurse is developing a plan of care for a client who is postoperative which of the following interventions should the nurse include in the plan to pr
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Nursing Elites

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ATI Detailed Answer Key Medical Surgical

1. A client is postoperative, and a nurse is developing a plan of care. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?

Correct answer: Encourage the use of an incentive spirometer

Rationale: Encouraging the use of an incentive spirometer is vital in preventing pulmonary complications postoperatively. The incentive spirometer helps the client perform deep breathing exercises, promoting lung expansion, and preventing atelectasis. Range-of-motion exercises help prevent musculoskeletal complications, while placing suction equipment at the bedside is important but not directly related to preventing pulmonary complications. Administering an expectorant may help with clearing secretions but is not as effective in preventing postoperative pulmonary complications as using an incentive spirometer.

2. A wound has a blood-tinged liquid that is dripping from the surgical site. How does the nurse document this finding?

Correct answer: Serosanguineous

Rationale:

3. A 6-year-old child with daytime enuresis complains of dysuria and urgency. What does the nurse recognize these signs and symptoms indicate?

Correct answer: A

Rationale: The signs and symptoms of dysuria and urgency in a child with daytime enuresis typically indicate a urinary tract infection (UTI). These symptoms, along with urinary frequency and pain during urination, are common manifestations of a UTI in children. Nephrotic syndrome is characterized by edema, proteinuria, hypoalbuminemia, and hyperlipidemia, rather than dysuria and urgency. Acute glomerulonephritis presents with hematuria, proteinuria, hypertension, and oliguria, not dysuria and urgency. Vesicoureteral reflux can lead to recurrent UTIs but does not directly cause dysuria and urgency.

4. You’re caring for Jane, a 57 y.o. patient with liver cirrhosis who develops ascites and requires paracentesis. Before her paracentesis, you instruct her to:

Correct answer: A

Rationale: Before paracentesis, instruct the patient to empty her bladder to avoid bladder injury during the procedure.

5. What action should be taken by nurses in the local community regarding the trash in the stream?

Correct answer: A

Rationale: Nurses play a crucial role in community health promotion. By engaging in dialogue with community members about the issue of trash in the stream and its impacts, nurses can raise awareness, foster community involvement, and encourage collective action towards a cleaner environment. This approach aligns with nursing principles of empowering individuals and communities to address health-related concerns collaboratively.

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