Final answer:
B. Administer IV bolus analgesic and return in 15 min. The nurse should administer an IV bolus analgesic and return in 15 minutes to effectively manage the client's pain and encourage the use of the Incentive Spirometer (IS).
Step-by-step explanation:
Based on the given information, the nurse should administer an IV bolus analgesic and return in 15 minutes. The client's decline in attempting to cough due to pain and fatigue indicates a need for pain management. Administering an IV bolus analgesic will help alleviate the client's pain, allowing them to effectively use the Incentive Spirometer (IS) to promote deep breathing and prevent complications such as atelectasis.A nurse is caring for a client who is 4 hr postoperative following Coronary Artery Bypass Graft (CABG) surgery. The client is only able to inspire 200 mL with the incentive spirometer (IS) and declines to try to cough due to fatigue and pain.
Among the actions available, the most appropriate would be to administer IV bolus analgesic and return shortly thereafter to assist the client. By managing the client's pain with an analgesic, you not only improve comfort but also facilitate their ability to perform critical postoperative pulmonary exercises, like coughing and deep breathing, which are essential for preventing complications such as atelectasis and pneumonia.After administering the pain medication, the nurse should return in 15 minutes to reassess pain and encourage the client to use the IS again, as well as perform the required coughing to maintain lung function. Documentation of the inspired volume is also necessary, yet it's more important to address the issue that is preventing the client from fulfilling the cough requirement. Allowing the client to rest without addressing the pain would not be conducive to optimal recovery. Telling the client coughing is required without offering pain relief would likely be unproductive and could dampen the nurse-client relationship.