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. "Both illnesses begin in the rectum." This statement is not accurate. Ulcerative colitis typically begins in the rectum and progresses proximally, while Crohn's disease can involve any part of the digestive tract.
b. "Both illnesses are inflammatory in nature." This is the correct statement. Both ulcerative colitis and Crohn's disease are inflammatory bowel diseases characterized by chronic
inflammation of the gastrointestinal tract.
c. "Both illnesses manifest fistula formation." Fistula formation is more commonly associated with Crohn's disease, not ulcerative colitis.
d. "Both illnesses result in malabsorption of nutrients." While malabsorption can occur in both conditions, it is generally more associated with Crohn's disease than ulcerative colitis.
Correct Answer is D
Explanation
a. Pleural friction rub: Pleural friction rub is a grating sound heard during inspiration and
expiration and is associated with inflammation of the pleura. It is not typically associated with asthma exacerbation.
b. Fine rales: Fine rales (crackles) are usually heard during inspiration and can be associated with conditions such as pneumonia or pulmonary fibrosis. They are not the typical lung sounds in
asthma exacerbation.
c. Rhonchi: Rhonchi are low-pitched wheezes heard during inspiration and expiration. While they can be associated with asthma, expiratory wheezes are more specific to asthma
exacerbation.
d. Expiratory wheeze: Expiratory wheezes are high-pitched, musical sounds heard during
expiration and are characteristic of asthma exacerbation. They result from narrowed airways and increased airway resistance.
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