can anyone explain me the rational

[NurseP1988]

103. The nurse is caring for a client who has just returned to the postsurgical unit following abdominal surgery for cancer of the colon. It is MOST appropriate for the nurse to take which of the following actions?

1. Determine the stage of loss and grief.

2. Analyze the quality and quantity of pain.

3. Instruct the client to cough and deep breathe.

4. Ask the client to lift his head off the pillow.

Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Remember Maslow.

(1) physical needs take priority

(2) not most important

(3) implementation, should first assess

(4) correct–should assess whether there are any remaining effects of neuromuscular blocking agents; may block ability to breathe deeply

[JustBeachyNurse, LPN]

Rationale--if the client hasn't recovered from the neuromuscular blocks sufficient to protect airway and effectively respirate this will cause an immediate life threatening complication more so than high levels of pain.

Not able to adequately breathe or maintain airway = death.

No point in instructing to cough & deep breathe until you have assessed whether the patient has the physical ability to do so.

[Okami_CCRN, BSN, RN]

This is one of those questions that you need to use something like the Kaplan decision tree to arrive at the correct answer. You can find the decision tree by a quick google image search.

Neuromuscular blockade agents (Pavulon, Nimbex, etc.) can have residual effects after discontinuation, patients are usually recovered from anesthesia in PACU but as the receiving nurse on the post-op floor you should determine if they are able to move all extremities independently and can breathe adequately. Asking the patient to lift their head up allows you to determine if they are able to move independently which means that the paralytic agents residual effects are gone.

[NurseP1988]

thank you so much both of you