The nurse assesses the client on the first postoperative day. Which is the most important client outcome requiring follow-up interventions by the nurse?
1. Pain level is 2 out of 10 after an analgesic.
2. Client voids 45 ml per hour postoperatively.
3. Bowel sounds are inaudible in all quadrants.
4. Performs breathing exercises every 6 to 8 hours.
4
4 and 3. Inaudible bowel sounds and infrequent breathing exercises postoperatively require follow-up nursing interventions; however, increasing the frequency of breathing exercises is more important because breathing is a vital function versus bowel sounds related to gastrointestinal function. The client decreases the risk of atelectasis and pneumonia postoperatively with frequent coughing, deep breathing, incentive spirometry, and ambulation.
1 and 2. The pain level at 2 and 45 ml per hour urine output are within normal limits for a postoperative client requiring routine postoperative nursing care.
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The nurse teaching a class on reproductive anatomy knows that no further instruction is needed when a student shows an understanding of the pelvic cavity divisions by making which statement?
1. "The true pelvis is made up of the sacrum, coccyx, and innominate bones." 2. "The false pelvis consists of the inlet, the pelvic cavity, and the outlet." 3. "The true pelvis is the portion above the pelvic brim." 4. "The relationship between the false pelvis and the fetal head is of paramount importance."
Nurses are effective and influential shapers of healthcare policy because of their expertise in: (Select all that apply.)
A) Clinical practice B) Administration C) Education D) Political science E) Research
The mother asks the nurse who establishes immunization schedules. The nurse would correctly educate the mother by making which statement?
1. The American Academy of Pediatrics 2. The Centers for Disease Control and Prevention 3. The American Medical Association 4. The Food and Drug Administration (FDA)
The nurse is discussing measures to minimize the risk of injury from an automobile accident with an 84-year-old independent female client who lives alone and claims to drive only to church, the doctor's office, and for groceries
Which of the following suggestions has the greatest potential for affecting the client's safety? a. Take public transportation whenever it is available. b. Plan all trips around church and doctor appointments. c. Plan to drive for short trips and only during daylight hours. d. Arrange for family and friends to drive the client whenever possible.