A nurse in a critical care unit is caring for a client who is postoperative following a right pneumonectomy. After extubation from the ventilator, in which of the following positions should the client be placed?

Prone

SemiFowler's

Sims

On the nonoperative side

Answer and Explanation

The Correct Answer is B

The correct answer is: d. On the nonoperative side

Choice A: Prone

Reason: Placing a patient in the prone position (lying face down) after a pneumonectomy is generally not recommended. This position can compromise respiratory function by restricting chest expansion and increasing the risk of respiratory complications. Additionally, it can place undue pressure on the surgical site, potentially leading to complications such as impaired wound healing or increased pain.

Choice B: Semi-Fowler’s

Reason: The Semi-Fowler’s position (head of the bed elevated to 30-45 degrees) is often used to promote lung expansion and reduce the risk of aspiration. While it can be beneficial for general postoperative care, it is not the optimal position for a patient who has undergone a pneumonectomy. This position does not specifically address the need to prevent fluid accumulation in the remaining lung.

Choice C: Sims

Reason: The Sims position (lying on the side with one leg bent) is typically used for procedures such as enemas or to facilitate drainage of oral secretions. It is not suitable for a postoperative pneumonectomy patient because it does not provide the necessary support to the remaining lung and can increase the risk of fluid shifting to the nonoperative side.

Choice D: On the nonoperative side

Reason: Placing the patient on the nonoperative side is the correct position. This position helps to prevent fluid from accumulating in the remaining lung and reduces the risk of complications such as mediastinal shift or respiratory distress. By positioning the patient on the nonoperative side, gravity helps to keep the remaining lung expanded and functional.

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Correct Answer is A

Explanation

Choice A reason: No fluctuations in the water seal chamber. This finding indicates that the lung has expanded and there is no more air leaking from the pleural space. Fluctuations in the water seal chamber are normal when the client breathes, but they should stop when the lung is fully expanded.

Choice B reason: No reports of pleuritic chest pain. This finding does not indicate that the lung has expanded, as pleuritic chest pain can be caused by other factors, such as inflammation or infection of the pleura. Pleuritic chest pain is a sharp pain that worsens with breathing or coughing.

Choice C reason: Occasional bubbling in the water seal chamber. This finding does not indicate that the lung has expanded, as occasional bubbling can be normal or due to a small air leak. Continuous bubbling, however, indicates a large air leak and requires immediate attention.

Choice D reason: Oxygen saturation of 95%. This finding does not indicate that the lung has expanded, as oxygen saturation can be normal or high even with a collapsed lung. Oxygen saturation is the percentage of hemoglobin that is bound to oxygen in the blood.

A. Administer low flow oxygen continuously via nasal cannula. B. Encourage oral intake of at least 3,000 mL of fluids per day. C. Offer high protein and high carbohydrate foods frequently. D. Place in a prone position.

Correct Answer is D

Explanation

Choice A reason: Administer low flow oxygen continuously via nasal cannula. This intervention is not appropriate because it does not provide enough oxygen to meet the needs of a client with ARDS. A client with ARDS requires high flow oxygen delivered by a mechanical ventilator or a noninvasive positive pressure device.

Choice B reason: Encourage oral intake of at least 3,000 mL of fluids per day. This intervention is not appropriate because it can worsen the pulmonary edema and hypoxemia that occur in ARDS. A client with ARDS requires fluid restriction and diuretics to reduce the fluid accumulation in the lungs.

Choice C reason: Offer high protein and high carbohydrate foods frequently. This intervention is appropriate because it provides adequate nutrition and energy to support the client's metabolic needs and prevent muscle wasting. A client with ARDS has increased caloric and protein requirements due to the increased work of breathing and the inflammatory response.

Choice D reason: Place in a prone position. This intervention is effective because it improves oxygenation and ventilation by increasing lung volume and reducing the effects of gravity on the lungs.

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A nurse in a critical care unit is caring for a client who is postoperative following a right pneumonectomy. After extubation from the ventilator, in which of the following positions should the client be placed?

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