Nursing Practice

What is the first step the nurse should take in response to Linda’s symptoms?

• Administer oxygen at a higher flow rate

• Call the physician immediately

• Perform a thorough assessment, including vital signs and lung sounds

• Increase IV fluid administration

Based on Linda’s symptoms, what nursing diagnosis is most appropriate?

• Risk for falls related to lethargy

• Impaired gas exchange related to decreased oxygen levels

• Acute pain related to surgical incision

• Knowledge deficit related to postoperative care

What is the most important intervention to include in the care plan for Linda?

• Encourage the patient to remain in bed to avoid pain

• Encourage early ambulation and assess for deep vein thrombosis (DVT)

• Administer additional pain medication to promote sleep

• Reduce oxygen therapy to prevent dependency

Which outcome indicates that the interventions have been effective?

• Linda reports increased drowsiness and less pain

• Linda’s oxygen saturation remains at 88% despite interventions

• Linda’s oxygen saturation improves to 96% and her temperature returns to normal

• Linda requires continuous oxygen therapy at a high flow rate

The nurse notes that Linda has been hesitant to participate in deep breathing exercises. What is the best approach to encourage participation?

• Explain the benefits of deep breathing and use an incentive spirometer

• Ignore her reluctance and continue care as planned

• Increase pain medication to make breathing exercises easier

• Tell her that if she does not comply, her condition will worsen

After implementing interventions, what is the final step of the nursing process?

• Planning the next steps

• Administering additional interventions

• Reassessing only if the doctor requests it

• Evaluating the effectiveness of interventions and adjusting care as needed