A nurse is assisting with the care of a school-age child who has respiratory failure due to pneumonia. Which of the following positions should the nurse encourage to allow maximal lung expansion?
Prone
Side-lying
Supine
Upright
The Correct Answer is D
Choice A reason: Prone is not the best position to allow maximal lung expansion. Prone is a position where the client lies on their stomach, with their head turned to one side. Prone can help to improve oxygenation in some cases of acute respiratory distress syndrome (ARDS), but it can also increase the risk of pressure ulcers, facial edema, and airway obstruction.
Choice B reason: Side-lying is not the best position to allow maximal lung expansion. Side-lying is a position where the client lies on their side, with their head supported by a pillow. Side-lying can help to prevent aspiration and reduce the work of breathing in some clients, but it can also compromise the ventilation of the dependent lung.
Choice C reason: Supine is not the best position to allow maximal lung expansion. Supine is a position where the client lies on their back, with their head and shoulders slightly elevated. Supine can help to maintain a patent airway and facilitate suctioning in some clients, but it can also increase the risk of atelectasis, pneumonia, and hypoxemia.
Choice D reason: Upright is the best position to allow maximal lung expansion. Upright is a position where the client sits or stands with their back straight and their chest expanded. Upright can help to improve lung compliance, reduce airway resistance, and enhance gas exchange in clients with respiratory failure. Upright can also reduce the pressure on the diaphragm and abdominal organs, and promote the drainage of secretions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Choice A: Iron supplements are used to treat iron-deficiency anemia, but they can also reduce the motility of the gastrointestinal tract and make the stools harder and drier¹². This can lead to difficulty in passing stools and increased straining.
Choice B: Magnesium-containing antacids are used to treat heartburn and acid reflux, but they can also have a laxative effect and cause diarrhea¹³. This is because magnesium draws water into the intestines and stimulates bowel movements.
Choice C: Antibiotics are used to treat bacterial infections, but they can also disrupt the normal flora of the gut and cause diarrhea¹⁴. This is because antibiotics can kill the beneficial bacteria that help digest food and prevent the overgrowth of harmful bacteria that cause inflammation and infection.
Choice D: Anticholinergics/antispasmodics are used to treat overactive bladder, irritable bowel syndrome, and other conditions that involve muscle spasms in the gut, but they can also slow down the movement of the intestines and relax the muscles that help push the stools out¹ . This can lead to reduced frequency and difficulty in defecation.
Choice E: Opioid narcotics are used to treat moderate to severe pain, but they can also block the signals from the brain to the gut and inhibit the contraction of the intestinal muscles¹ . This can lead to decreased bowel activity and accumulation of hard and dry stools.
Correct Answer is C
Explanation
The correct answer is c. Muscle weakness.
Choice A: Hypertension
Reason: Hypertension, or high blood pressure, is not a typical manifestation of hypokalemia. Hypokalemia primarily affects muscle function and the nervous system. While potassium imbalances can influence blood pressure, hypertension is more commonly associated with hyperkalemia (high potassium levels) rather than hypokalemia.
Choice B: Cerebral Edema
Reason: Cerebral edema, which is swelling of the brain, is not a known manifestation of hypokalemia. Hypokalemia affects muscle and nerve function, but it does not directly cause cerebral edema. This condition is more related to severe head injuries, infections, or other medical conditions.
Choice C: Muscle Weakness
Reason: Muscle weakness is a common and significant manifestation of hypokalemia. Potassium is crucial for muscle function, and low levels can lead to muscle weakness, cramps, and even paralysis in severe cases. This is because potassium helps in the transmission of nerve signals to muscles, and a deficiency disrupts this process.
Choice D: Hyperactive Bowel Sounds
Reason: Hyperactive bowel sounds are not typically associated with hypokalemia. In fact, hypokalemia can lead to decreased bowel motility, resulting in symptoms like constipation or ileus (a condition where the intestines do not move properly). This is due to the role of potassium in muscle contractions, including those in the digestive tract.
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