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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Free Nursing Study Resources

Correct Answer is A

Explanation

a. Potassium level of 3.0 mEq/L: Hypokalemia is a potential adverse effect of digoxin, and a

potassium level of 3.0 mEq/L is below the normal range. Low potassium levels can increase the risk of digoxin toxicity.

b. Heart rate of 66/min: A heart rate of 66/min is within the normal range. Digoxin is used to

treat conditions like atrial fibrillation, and the heart rate should be within an appropriate range for the client's condition.

c. BP of 132/82 mm Hg: Blood pressure within the normal range does not require immediate reporting in the context of digoxin administration.

d. Digoxin level of 1.2 ng/ml: The digoxin level of 1.2 ng/ml is within the therapeutic range, and it does not require immediate reporting.

A. Tetany B. Constipation C. Negative Chvostek sign D. Elevated blood pressure

Correct Answer is A

Explanation

a. Tetany: A calcium level of 8 mg/dl is low and can be associated with tetany.

b. Constipation:This is associated with hypercalcemia as opposed to hypocalcemia

c. Negative Chvostek sign: A positive Chvostek sign is associated with hypocalcemia, not hypercalcemia.

d. Elevated blood pressure: Elevated calcium levels are not typically associated with elevated blood pressure. Hypertension is not a common manifestation of hypercalcemia.

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