Question

Two (2) days after a colectomy, a client's breath sounds are diminished and the vital signs are: Temperature 100.2, respirations 24, pulse 104, and BP 136/84. Which nursing actions prevent post-operative complications? Mark all that apply.

a. The application of TED hose
b. Encouraging the use of the incentive spirometer
c. Increasing intravenous and oral fluids
d. Encouraging the client to turn, cough, and deep breath
e. Assisting the client with all activities of daily living

Answer 1

To prevent post-operative complications, nurses should encourage the use of the incentive spirometer and encourage the client to turn, cough, and deep breathe. Assistance with activities of daily living may be helpful but is not directly related to preventing respiratory complications.

Step-by-step explanation:

The client's post-operative condition, with diminished breath sounds and elevated vital signs, suggests a risk of complications such as pneumonia or atelectasis. To prevent post-operative complications, the following nursing actions are appropriate:

• Encouraging the use of the incentive spirometer: This helps to expand the lungs and prevent atelectasis.
• Encouraging the client to turn, cough, and deep breathe: This aids in clearing secretions and maintaining lung volumes.
• Assisting the client with activities of daily living: While this is generally helpful, it is not directly related to preventing respiratory complications.

While the application of TED hose and increasing intravenous and oral fluids can be beneficial for other reasons, such as preventing deep vein thrombosis and maintaining hydration, they are not specifically targeted at preventing respiratory post-operative complications.