For which nursing diagnoses or collaborative problems common in postoperative patients has ambulation been found to be an appropriate intervention (select all that apply)?

Correct Answer: D

Rationale: In the context of postoperative care, the correct answer is D) Ineffective airway clearance related to decreased respiratory excursion. Ambulation is an appropriate intervention for this nursing diagnosis because mobilizing the patient helps promote lung expansion and clearance of secretions, thereby improving airway clearance and preventing respiratory complications like atelectasis and pneumonia. Option A) Impaired skin integrity related to incision is not directly addressed by ambulation. While early ambulation can indirectly promote overall wound healing by improving circulation, it is not a primary intervention for this nursing diagnosis. Option B) Impaired mobility related to decreased muscle strength may benefit from ambulation, but it is not a common nursing diagnosis in postoperative patients. This option does not directly address the respiratory issues that ambulation can help alleviate. Option C) Risk for aspiration related to decreased muscle strength is a serious concern postoperatively, but ambulation alone may not be sufficient to address this problem. Other interventions such as proper positioning and monitoring swallowing function are more directly related to preventing aspiration. In adult medical-surgical nursing, understanding the rationale behind interventions is crucial for providing effective and evidence-based care. Ambulation plays a key role in postoperative care by improving respiratory function, preventing complications, and promoting overall recovery. It is important for nurses to prioritize interventions that directly address the identified nursing diagnoses to ensure optimal patient outcomes.

Correct Answer: C

Rationale: In this scenario, option C is the correct answer as it indicates that Mr. Jones understands his postoperative regimen. By choosing to watch baseball games on TV instead of driving to the stadium, Mr. Jones demonstrates an understanding of the importance of avoiding activities that could strain him post-surgery, such as driving or engaging in physical exertion. Option A is incorrect because it shows a plan to go to an amusement park and ride roller coasters, which could pose a risk to Mr. Jones' recovery due to the physical demands and potential for injury. Option B is incorrect as it suggests reliance on someone else for basic self-care tasks that Mr. Jones should be able to manage independently after discharge. Option D is incorrect as it focuses on retirement due to job requirements, which is not directly related to understanding postoperative care. This question assesses the patient's comprehension of their discharge instructions and ability to make appropriate choices for their recovery. Educationally, this question highlights the importance of patient education in promoting postoperative recovery and preventing complications. It emphasizes the need for patients to comprehend and follow their discharge instructions to ensure a successful outcome and reduce the risk of readmission or postoperative issues.

Correct Answer: C

Rationale: In the context of assisting a patient with impaired vision due to patches on both eyes, the correct option (C) advises the family member to offer their arm and walk in front of Mr. Johnstone. This is the most appropriate choice because walking in front allows the family member to guide and support Mr. Johnstone effectively by leading him and providing verbal cues about obstacles or changes in terrain. This position also enables the family member to maintain visual contact with Mr. Johnstone, ensuring his safety during the walk. The incorrect options (A) and (D) suggest walking behind Mr. Johnstone, which may not provide adequate support and guidance, especially considering his impaired vision. Walking behind him can lead to potential accidents or falls as the family member may not be able to offer timely assistance or communicate effectively with him. Option (B) of grasping him by the arm and walking in front of him is not ideal as it may cause discomfort or anxiety for Mr. Johnstone by invading his personal space and impeding his movement. Educationally, this scenario highlights the importance of understanding the specific needs of patients with visual impairments and the appropriate techniques for assisting them in mobility. It emphasizes the significance of positioning, communication, and support in ensuring the safety and well-being of individuals with temporary or permanent vision loss. By choosing the correct option, the family member can provide effective assistance to Mr. Johnstone during his recovery period.

Correct Answer: C

Rationale: In planning Mrs. Filbert's care during an acute attack of Meniere disease, the most important action would be to instruct her about prescribed dietary modifications (Option C). Meniere disease is characterized by inner ear fluid imbalance, leading to vertigo and dizziness. Dietary modifications, such as reducing salt intake, can help manage symptoms by reducing fluid retention in the inner ear. This intervention directly addresses the physiological root of the condition. The other options are less relevant or potentially detrimental in this situation. Option A focuses on emotional support, which is important but not the priority during an acute attack. Option B, keeping siderails up and assisting with mobility, may be important for fall prevention but does not address the acute symptoms of Meniere disease. Option D, encouraging ambulation, could exacerbate symptoms like vertigo and nausea during an acute attack. In an educational context, understanding the rationale behind prioritizing interventions based on the pathophysiology of a condition is crucial for providing safe and effective patient care. By choosing the correct intervention, healthcare providers can improve patient outcomes and quality of care.

Correct Answer: B

Rationale: In the context of an adult medical surgical emergency, the correct action when a patient with a high blood alcohol level (BAL) of 0.48 is unconscious is to immediately call the ED practitioner (Option B). This is essential because an unconscious patient with such a high BAL may be at risk of severe alcohol poisoning, which can be life-threatening and requires prompt medical intervention. Placing the patient in a quiet area and waiting for the patient to sober up (Option A) is not appropriate in this situation as the patient's condition could rapidly deteriorate without medical attention. Administering Narcan (Option C) is used for opioid overdose, not alcohol intoxication. Sending the patient to the ICU immediately (Option D) may be premature without first consulting with the ED practitioner to determine the appropriate course of action based on the patient's presentation and condition. Educationally, this scenario highlights the importance of rapid assessment and appropriate decision-making in emergency situations. Understanding the effects of alcohol intoxication, the potential complications of high BAL levels, and the appropriate steps to take in managing such cases is crucial for healthcare providers working in emergency settings.