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 C

Explanation

a. Bile: The guaiac test is not used to detect bile in the stool.

b. Lipids: The guaiac test is not used to detect lipids in the stool.

c. Blood: The guaiac test, also known as the fecal occult blood test (FOBT), is used to detect hidden (occult) blood in the stool. It is commonly used as a screening test for colorectal cancer.

d. Bacteria: The guaiac test is not used to detect bacteria in the stool.

A. Maintain the client on bed rest. B. Strain the client's urine through a mesh filter. C. Encourage fluid intake of 1500 mL/day. D. Clamp the urinary catheter every 2 hr.

Correct Answer is B

Explanation

a. Maintain the client on bed rest: While rest may be indicated in some cases, it is not a specific intervention for managing renal stones with a urinary catheter.

b. Strain the client's urine through a mesh filter: Straining urine is essential to collect any stones that may have passed, allowing for analysis and identification.

c. Encourage fluid intake of 1500 mL/day: Adequate fluid intake is crucial to prevent stone formation, but the amount may vary depending on the client's specific needs and condition.

d. Clamp the urinary catheter every 2 hr: Clamping the urinary catheter is not a standard

intervention for managing renal stones. Straining the urine for stone collection is a more relevant intervention.

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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

A nurse is preparing to collect a specimen from a client for a guaiac test. The client asks what the test will detect in his stool. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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