The nurse is teaching a male client who has chronic obstructive pulmonary disease (COPD) before open-heart surgery
Which should the nurse include in client teaching to prevent compli-cations directly related to his chronic illness? (Select all that apply.) 1. Maintain hydration.
2. Perform leg exercises.
3. Control incisional pain.
4. Cough and deep breathe.
5. Use incentive spirometry.
6. Ambulate three times daily.
1, 3, 4, 5
1. The nurse teaches the client to prevent dehydration to maintain thin pulmonary se-cretions for easier expectoration. The nurse encourages the client to drink adequate fluids and to avoid dehydrating agents such as caffeinated beverages.
3 and 4. The nursing instructs the client to control incisional pain, facilitating post-operative airway clearance with turning, coughing, and deep breathing. After a tho-racotomy, the client is unlikely to be willing to perform these activities with incisional pain; thus, the nurse includes teaching about pain management and splinting the wound for coughing and getting out of bed to increase client comfort.
5. The nurse instructs the client preoperatively about incentive spirometry (IS) be-cause the nurse uses IS to promote lung expansion with prolonged inhalation to re-verse atelectasis.
2 and 6. The nurse encourages the client to perform leg exercises and to ambulate for the prevention of venous stasis and DVT formation.
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