Several hours after returning from surgery, the nurse tells the patient that she is ordered to be ambulated. The patient asks, "Why?" Which of the following complications would the nurse correctly explain can be prevented by early postoperative ambulation?

Correct Answer: C

Rationale: Early postoperative ambulation is important for preventing complications such as pneumonia. When a patient remains immobile for an extended period after surgery, they are at an increased risk of developing pneumonia due to decreased lung expansion and secretions pooling in the lungs. Ambulation helps improve lung function, promote better oxygenation, and prevent respiratory complications like pneumonia. In contrast, increased peristalsis helps prevent constipation, coughing helps prevent respiratory complications as well, and wound healing is not directly related to the need for early postoperative ambulation.

Correct Answer: A

Rationale: In the context of pediatric pharmacology and care after heart transplantation, it is crucial for nurses to understand the signs of organ rejection. The correct answer, "A) Low white blood cell count," is a key indicator of organ rejection in a post-transplant patient. A decrease in white blood cells may signify the body's immune response attacking the transplanted organ, leading to rejection. Dyspnea (B), ECG changes (C), and fever (D) are common symptoms in various clinical scenarios but are not specific to organ rejection after a heart transplant. Dyspnea can occur due to various reasons including heart failure or respiratory issues post-surgery. ECG changes can occur due to electrolyte imbalances or surgical stress. Fever can be a sign of infection, inflammation, or other post-operative complications. Educationally, it is important for nurses to recognize the unique signs and symptoms of organ rejection in pediatric patients after heart transplantation to ensure timely intervention and prevent complications. Understanding these specific indicators helps in early detection and management of rejection episodes, ultimately improving patient outcomes and quality of life. Nurses play a critical role in post-transplant care by monitoring closely for signs of rejection and collaborating with the healthcare team for appropriate interventions.

Correct Answer: B

Rationale: The nursing intervention of teaching the client about non-pharmacologic and pharmacologic methods for restoring blood pressure is crucial in managing hypertension. Education empowers the client to actively participate in their care and make informed decisions regarding lifestyle changes, medication adherence, and other interventions to control their blood pressure levels. By providing education on interventions such as dietary modifications, exercise, stress management, and medication use, the nurse helps the client develop a comprehensive plan to manage hypertension effectively and improve their overall health outcomes.

Correct Answer: B

Rationale: The best response by the nurse is to address the situation with understanding and empathy. Referring to the patient as a "dirty old man" is disrespectful and unprofessional. The nurse should acknowledge that the patient's behavior may be a result of the stroke affecting his inhibitions and offer a solution to find a male assistant to help him, recognizing the nursing assistant's discomfort while still providing care for the patient. It is important to prioritize the well-being and comfort of both the patient and the staff while maintaining professionalism and dignity in the care provided.

Correct Answer: D

Rationale: The best way to assess whether a patient is breathing is to observe the movement of the chest and nostrils. Chest movement indicates inhalation and exhalation, while the nostrils may flare during breathing. Observing these two areas provides a more direct and accurate assessment of breathing compared to extremities, head, or eyeball movements. By focusing on the chest and nostrils, a nurse can quickly and effectively determine if a patient is breathing adequately.