A nurse is assisting with the care of a client who is postoperative following a pneumonectomy. Which of the following actions should the nurse take?
Position the client on the nonoperative side.
Monitor respiratory status every 8 hr.
Elevate the head of the bed to a 15° angle.
Encourage the client to splint the incision when coughing.
The Correct Answer is D
a. Position the client on the nonoperative side: The client should be positioned on the operative side to facilitate expansion of the remaining lung.
b. Monitor respiratory status every 8 hr: Postoperative respiratory status should be monitored more frequently than every 8 hours to assess for complications, especially in the initial
postoperative period.
c. Elevate the head of the bed to a 15° angle: The head of the bed should be elevated to a higher angle (usually 30-45 degrees) to promote optimal lung expansion and reduce the risk of
complications such as atelectasis.
d. Encourage the client to splint the incision when coughing: Encouraging the client to splint the incision when coughing helps minimize pain and supports effective coughing to prevent
complications such as atelectasis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a.The statement "I will drink plenty of fluids after the test" indicates the client's understanding that hydration is important after the procedure, which is also a crucial aspect of post-procedure care. This response suggests the client understands the need to stay hydrated after ingesting barium, which helps eliminate the contrast material from the body and prevents constipation.
b. “I will expect my stool to be black after this procedure.”: The statement is related to the potential side effects of barium, but it does not address the pre-test instructions.
c. “I will expect a warm feeling when the dye is injected.”: This statement may relate to the sensation during the test but does not address the pre-test instructions.
d.while fasting may be required before the test, a clear liquid diet is not typically maintained for 24 hours prior to the procedure.
Correct Answer is C
Explanation
a. Type A: Type A blood may not be compatible with the client's blood type, and it is not considered a universal donor.
b. Type B: Similar to Type A, Type B blood may not be compatible with the client's blood type, and it is not considered a universal donor.
c. Type O: Type O negative blood is considered the universal donor for packed red blood cells. It can be administered to individuals with any blood type in an emergency situation.
d. Type AB: While Type AB is considered the universal recipient for blood transfusions, it is not the universal donor.
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