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 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.

A. Ask the client to read a Snellen chart. B. Ask the client to clench his teeth. C. Listen to the client’s speech. D. Ask the client to identify scented aromas.

Correct Answer is A

Explanation

Choice A reason: Ask the client to read a Snellen chart. This method is used to assess cranial nerve II, which is the optic nerve. The optic nerve is responsible for vision and visual acuity. A Snellen chart is a tool that displays letters of different sizes and measures how well the client can see them from a distance of 20 feet.

Choice B reason: Ask the client to clench his teeth. This method is not used to assess cranial nerve II, but cranial nerve V, which is the trigeminal nerve. The trigeminal nerve is responsible for sensation and motor function of the face, mouth, and jaw. Clenching the teeth tests the strength and symmetry of the masseter and temporalis muscles, which are innervated by the trigeminal nerve.

Choice C reason: Listen to the client’s speech. This method is not used to assess cranial nerve II, but cranial nerves IX, X, and XII, which are the glossopharyngeal, vagus, and hypoglossal nerves. These nerves are responsible for speech production and swallowing. Listening to the client’s speech tests the quality, clarity, and articulation of the voice, as well as the movement and coordination of the tongue and palate.

Choice D reason: Ask the client to identify scented aromas. This method is not used to assess cranial nerve II, but cranial nerve I, which is the olfactory nerve. The olfactory nerve is responsible for smell and olfaction. Asking the client to identify scented aromas tests the ability to detect and recognize different odors.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan?

Correct Answer is D

Explanation

A nurse is assessing a client’s cranial nerves. Which of the following methods should the nurse use to assess cranial nerve II?

Correct Answer is A

Explanation

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