a nurse is developing a plan of care for a client who is 12 hr postoperative following colon resection which of the following interventions should the
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Nursing Elites

ATI RN

Adult Medical Surgical ATI

1. A client is 12 hours postoperative following colon resection. Which of the following interventions should the nurse include in the plan to reduce respiratory complications?

Correct answer: D

Rationale: Following a colon resection surgery, it is essential to support the incision site to reduce the risk of respiratory complications. Splinting the incision helps to minimize pain during coughing, aiding in effective clearing of secretions and preventing respiratory problems. This intervention supports the client's respiratory function postoperatively, promoting optimal recovery.

2. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP) for a client receiving O2 at 4 liters per nasal cannula?

Correct answer: A

Rationale: When a client is receiving oxygen at a high flow rate, it can cause drying of the nasal passages and lips. Therefore, a comfort measure that can be delegated to unlicensed assistive personnel (UAP) is applying water-soluble ointment to the client's nares and lips. Adjusting the oxygen flow rate should be done by licensed nursing staff, not UAP. Removing the tubing can disrupt the oxygen delivery and should be performed by trained personnel. Turning the client every 2 hours is a general comfort measure but is not specific to addressing the drying effects of oxygen therapy.

3. A client with chronic obstructive pulmonary disease (COPD) is being assessed by a nurse. Which finding does the nurse expect?

Correct answer: A

Rationale: Clients with COPD commonly develop a barrel chest, characterized by an increased anteroposterior diameter of the chest. This change is due to chronic air trapping and hyperinflation of the lungs. A decreased respiratory rate, weight gain, and productive cough with yellow sputum are not typical findings in COPD. Instead, COPD patients often present with an increased respiratory rate, weight loss, and a chronic cough with sputum production.

4. A newly graduated nurse in the hospital states that, since she is so new, she cannot participate in quality improvement (QI) projects. What response by the precepting nurse is best?

Correct answer: B

Rationale: The best response is to encourage the newly graduated nurse to actively participate in quality improvement initiatives. Being new does not preclude one from contributing to improving care processes and outcomes. By engaging in small activities focused on quality improvement, the new nurse can start making a positive impact and learn valuable skills early in their career.

5. A client with dyspnea and difficulty climbing stairs is classified as having class III dyspnea. Which intervention should the nurse include in the client's plan of care?

Correct answer: A

Rationale: Class III dyspnea indicates significant limitations in activity due to shortness of breath. Clients with this level of dyspnea should be encouraged to participate in activities within their tolerance levels. Providing assistance with activities of daily living helps conserve energy for essential tasks while promoting independence. Oxygen therapy is only necessary if hypoxia is present, and complete bedrest is generally not recommended for clients with dyspnea unless specifically indicated.

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