Practice Question
Client is 1 day postoperative following an open appendectomy.
Answer Choices:
Correct Answer:
Administer supplemental oxygen.
Rationale:
🟦 Administer supplemental oxygen. The client’s oxygen saturation has declined to 92%, indicating impaired respiratory effort and reduced alveolar ventilation.
🟦 Supplemental oxygen helps improve oxygenation while addressing underlying postoperative hypoventilation.
🟦 This intervention supports respiratory status until lung expansion improves.
🟦 Ambulate the client 30 min after administering analgesia. Ambulation enhances lung expansion and prevents postoperative atelectasis, especially crucial with diminished breath sounds and crackles.
🟦 Administering analgesia first reduces pain, making movement more tolerable and safer.
🟦 Early mobilization improves ventilation and overall respiratory function.
🟦 Instruct the client to use the incentive spirometer five times per hour.Incentive spirometry promotes deep inspiration, improving alveolar inflation and preventing atelectasis.
🟦 The client's shallow respirations and crackles show a need for lung recruitment exercises.
🟦 Frequent use improves oxygenation and reduces postoperative pulmonary complications.
🟦 Encourage the client to cough and breathe deeply. Deep breathing improves ventilation and helps mobilize trapped air in the lower lobes where crackles are present.
🟦 Coughing aids in clearing secretions that may worsen gas exchange.
🟦 These exercises are essential after abdominal surgery to prevent pneumonia.
🟦 Encourage the client to splint the abdomen. Splinting reduces incisional pain during coughing and deep breathing, making respiratory exercises more effective.
🟦 It increases cooperation because the client feels more secure during movement.
🟦 This promotes adequate ventilation while protecting the surgical site.
Administer acetaminophen.
🟦 The client does not have a fever that requires acetaminophen at this time.
🟦 Acetaminophen does not improve respiratory status and is unrelated to the current problem.
Administer ondansetron.
🟦 The client reports no nausea at 1000.
🟦 Treating nausea does not promote respiratory status in this scenario.
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This question is from RN Fundamentals Final 2023 -Fall 2025 which contains 72 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Fundamentals of Nursing
- Answer Choices: 7