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. Droplet precautions B. Airborne precautions C. Standard precautions D. Contact precautions

Correct Answer is C

Explanation

a. Droplet precautions: Droplet precautions are used for diseases that are transmitted by

respiratory droplets, such as influenza or pneumonia. HIV is not transmitted through respiratory droplets.

b. Airborne precautions: Airborne precautions are used for diseases that are transmitted through the airborne route, such as tuberculosis. HIV is not transmitted through the airborne route.

c. Standard precautions: Standard precautions are used for the care of all patients, regardless of their diagnosis. These precautions include hand hygiene, use of personal protective equipment (PPE) as needed, and safe injection practices.

d. Contact precautions: Contact precautions are used for diseases that are spread by direct or indirect contact, such as methicillin-resistant Staphylococcus aureus (MRSA). HIV is not

transmitted through contact with intact skin.

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