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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

a. Overusing a muscle while jogging: Overuse injuries are more commonly associated with strains, not sprains. Strains involve the muscles or tendons.

b. Twisting a ligament while walking: This is an example of a mechanism that can lead to a sprain. A sprain involves the stretching or tearing of ligaments, which connect bone to bone.

c. Impact injury on a joint from a fall: This is more likely to result in a sprain, as it can cause damage to ligaments.

d. Crush injury to a bone from blunt trauma: This type of injury is more likely to affect bones rather than ligaments or tendons, and it would not be considered a sprain or strain.

A. C-reactive protein B. Serum creatinine C. Antinuclear antibody D. Erythrocyte sedimentation rate

Correct Answer is B

Explanation

a. C-reactive protein: This is a marker of inflammation and is not specific to renal function. It is more commonly used to assess inflammation in various conditions.

b. Serum creatinine: Elevated levels of serum creatinine are indicative of impaired renal

function. Creatinine is a waste product that is normally filtered by the kidneys. Increased levels suggest decreased renal filtration.

c. Antinuclear antibody: This test is used to diagnose autoimmune diseases like SLE but does not directly measure renal function.

d. Erythrocyte sedimentation rate: This is a nonspecific marker of inflammation and is not directly related to renal function.

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