The postoperative nurse is planning care for a client recovering from major thoracic surgery. Which nursing diagnoses should the nurse select to plan for this client's immediate care needs?
Select all that apply.
A) Risk for Impaired Gas Exchange
B) Risk for Decreased Cardiac Output
C) Risk for Ineffective Airway Clearance
D) Risk for Imbalanced Nutrition: Less than Body Requirements
E) Risk for Imbalanced Fluid Volume
Answer: A, B, E
Nursing diagnoses appropriate for the immediate postoperative phase include the Risk for Impaired Gas Exchange because of anesthesia medications and hypothermia, the Risk for Decreased Cardiac Output because of anesthesia, and the Risk for Imbalanced Fluid Volume because of blood loss and nothing by mouth status. The Risk for Ineffective Airway Clearance might be appropriate later as the client recovers from surgery. There is no Risk for Imbalanced Nutrition: Less than Body Requirements during the immediate postoperative phase.
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