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 B
Explanation
a. Asthma: While asthma can cause dyspnea and fatigue, it is not typically associated with tachycardia and edema.
b. Heart failure: Heart failure is characterized by symptoms such as dyspnea, fatigue,
tachycardia, and edema. Tachycardia may be a compensatory response to maintain cardiac output, and edema can result from fluid retention.
c. Aortic valve regurgitation: Aortic valve regurgitation may cause symptoms such as dyspnea and fatigue, but it is not typically associated with tachycardia and edema.
d. Aortic stenosis: Aortic stenosis may lead to symptoms such as dyspnea, but tachycardia and edema are not typical features of aortic stenosis.
Correct Answer is C
Explanation
a. An endometrial biopsy: An endometrial biopsy is not the preferred method for detecting cervical cancer. It is more commonly used to evaluate the endometrium.
b. CA 125: CA 125 is a tumor marker used more for ovarian cancer detection and monitoring, not cervical cancer.
c. Papanicolaou test: The Papanicolaou test, also known as a Pap smear, is the preferred method for detecting cervical cancer and precancerous changes.
d. Transvaginal ultrasound: While ultrasound may be used to evaluate gynecological conditions,
it is not the primary method for detecting cervical cancer; the Pap smear is the standard screening test.
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