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 A

Explanation

a. Increasing dyspnea: Atelectasis is the collapse of alveoli, leading to decreased lung volume and impaired gas exchange. Dyspnea (difficulty breathing) is a common symptom as the lung's ability to oxygenate the blood is compromised.

b. Dry cough: A dry cough may be present, but it is not specific to atelectasis. It can occur for various reasons postoperatively.

c. Facial flushing: Facial flushing is not a typical finding in atelectasis. It is more commonly associated with conditions such as fever or allergic reactions.

d. Decreasing respiratory rate: Atelectasis can lead to increased respiratory rate as the body tries to compensate for decreased lung function. A decreasing respiratory rate would be less likely in the presence of atelectasis.

A. Emesis of 100 mL B. Oral temperature of 37.5" C (99.5° F) C. Pain level of 4 on a 0 to 10 rating scale D. Thick, red-colored urine

Correct Answer is D

Explanation

a. Emesis of 100 mL: While emesis is a concern, the priority is to address potential complications related to the surgical procedure first.

b. Oral temperature of 37.5" C (99.5° F): This temperature is within a normal range, and it is not an immediate concern.

c. Pain level of 4 on a 0 to 10 rating scale: Pain is important to address, but the priority is to assess for potential complications such as bleeding or infection.

d. Thick, red-colored urine: This finding suggests the possibility of bleeding, which could be a complication of the TURP procedure. It is the priority finding to report to the provider for further evaluation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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