A client recovering from surgery asks the nurse why turning, deep breathing, and coughing exercises need to be done. How should the nurse respond?

"These exercises prevent thrombophlebitis."

"The doctor ordered the exercises."

"These exercises help prevent pneumonia."

"All surgical clients must do these exercises."

The correct answer and explanation is:

Answer and Explanation

The Correct Answer is C

Turning, deep breathing, and coughing exercises are important for clients recovering from surgery as they help prevent the development of pneumonia. After surgery, clients may have difficulty taking deep breaths and coughing due to pain or discomfort. This can lead to the accumulation of mucus in the lungs, increasing the risk of pneumonia. By performing these exercises, clients can help clear their lungs and reduce their risk of developing this complication. While these exercises may also help prevent other complications such as thrombophlebitis, the primary reason for performing them is to prevent pneumonia.

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Correct Answer is ["A","D"]

Explanation

A test to determine the amount of residual urine is used to measure the amount of urine that remains in the bladder after voiding. This assessment can be used for several reasons, including to determine the need for medications that can help improve bladder emptying and to evaluate the amount of retained urine after voiding. Retained urine can increase the risk of urinary tract infections and other complications. This test is not typically used to evaluate ﬂuid volume status, glomerular filtration rate, or the extent of renal failure.

A. Risk for Injury B. Altered Tissue Perfusion C. Impaired Tissue Integrity D. Impaired Skin Integrity

Correct Answer is D

Explanation

A stage II pressure ulcer is a wound that involves partial-thickness loss of skin. The most appropriate NANDA nursing diagnosis problem statement for a client with this condition would be Impaired Skin Integrity. This diagnosis reﬂects the fact that the client's skin has been damaged and is no longer intact. Risk for Injury, Altered Tissue Perfusion, and Impaired Tissue Integrity are also NANDA nursing diagnoses, but they are not as specific or relevant to the client's condition as Impaired Skin Integrity.

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A client recovering from surgery asks the nurse why turning, deep breathing, and coughing exercises need to be done. How should the nurse respond?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client needs a test to determine the amount of residual urine. The nurse realizes that this assessment is used for which reason(s)? Select all that apply.

Correct Answer is ["A","D"]

Explanation

The client has a documented stage II pressure ulcer on the right hip. What NANDA nursing diagnosis problem statement is most appropriate to use with this client?

Correct Answer is D

Explanation

A client who has been blinded as a result of an injury has informed the nurse of her plans to return to her counselling practice and work full-time. The nurse should realize that this client is demonstrating which aspect of values clarification?

When planning interventions to promote a client's appetite, which of the following would be included in the client's plan?

A client has a history of an inconsistent fecal elimination pattern. What should the nurse instruct this client to improve this health problem?

The attributes of a professional nurse are:

A nurse is caring for an older adult client who is at risk for skin breakdown. The nurse should use which of the following interventions to help maintain the integrity of the client's skin?

The nurse is admitting a new client to the unit. The nurse notes that this client would need an alternate meal choice when the menu specified pork for a meal. Members of which cultural group might request an alternative meal choice?

While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. What is the correct name of this wound?

While in the dining room at the hospital, the nurse notes a visitor has forceful coughs. Which actions would the nurse take to assist this visitor? Select all that apply: