73. To promote maximum ventilation in a client who is postoperative, a nurse should:
. Auscultate breath sounds bilaterally.
. Give humidified oxygen via cannula.
. Maintain placement of airway until the client is awake.
. Position the client on the side, with the neck extended.
Test-Taking Tip
Think: "ABCs" and select "airway" as the action that is most important. The best choice will increase the effectiveness of the other options.
Content Area: Adult Health, Respiratory; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Complications from Surgical Procedures and Health Alterations
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Answer 1 is incorrect because keeping the airway open is more important than listening to breath sounds. Answer 2 is incorrect because keeping the airway open is the priority, not giving oxygen. Answer 3 is correct because, until fully awake, the tongue may obstruct the airway. Keeping the airway in place until the client pushes it out prevents obstruction. Answer 4 is incorrect because keeping the airway open is the priority. Side-lying may prevent aspiration in the client who may vomit, but it may not be possible, depending on type of surgery.