A nurse is caring for a school-age child suffering from respiratory failure due to pneumonia.
Which position should the nurse recommend for maximum lung expansion?

Prone

Side-lying

Supine

Upright

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Prone The prone position, in which a patient lies facedown, is beneficial for patients with pneumonia as it helps shift the fluid away from the back of the lungs, allowing more air to enter. It also improves ventilation in the lungs and reduces the risk of lung collapse. However, this position is not the most effective for maximum lung expansion in pneumonia patients.

Choice B rationale:

Side-lying Lateral positioning, in which the patient lies on one side, is recommended for patients suffering from pneumonia in just one lung. In this position, the pneumatic lung is exposed to a higher blood flow, resulting in greater oxygenation levels and improved lung expansion. This position can also help prevent lung injury by helping regulate pressure and improve aeration.

But again, this is not the most effective position for maximum lung expansion in pneumonia patients.

Choice C rationale:

Supine The supine position, where the patient lies flat on their back, is not the best position for a pneumonia patient. This position can cause the secretions to pool in the lungs, making it harder for the patient to breathe and potentially worsening their condition. Choice D rationale:

Upright Elevating the head of the bed is an effective way to improve lung expansion and oxygenation levels in pneumonia patients. This position also helps eliminate airway obstruction, reduces pressure on the lungs, and promotes drainage of fluids from the lungs. Therefore, the upright position is the most recommended for maximum lung expansion in pneumonia patients.

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Correct Answer is C

Explanation

Choice A rationale:

Hypothermia, or abnormally low body temperature, is not typically a symptom of diarrhea. While it’s possible for a person with severe diarrhea to experience chills or feel cold, hypothermia is not a direct result of diarrhea.

Choice B rationale:

A rigid abdomen is often a sign of a serious condition like peritonitis (inflammation of the peritoneum, the tissue that lines the inner wall of the abdomen), but it is not typically associated with diarrhea.

Choice C rationale:

Dehydration is a common complication of diarrhea. When a person has diarrhea, they can lose a lot of fluid and electrolytes quickly, leading to dehydration. Symptoms of dehydration can include thirst, less frequent urination, dark-colored urine, fatigue, dizziness, and confusion.

Choice D rationale:

Decreased bowel sounds are not typically associated with diarrhea. In fact, bowel sounds may actually increase in some cases of diarrhea due to increased gut motility.

A. The nurse applies the sterile drape after cleaning the perineal area. B. The nurse lubricates the indwelling urinary catheter. C. The nurse separates the patient’s labia with her dominant hand. D. The nurse provides perineal care prior to inserting the urinary catheter.

Correct Answer is C

Explanation

The correct answer is choice C.

Choice A rationale:

The nurse applies the sterile drape after cleaning the perineal area. This is correct because the perineal area should be cleaned before applying the sterile drape. Applying the drape first could potentially introduce bacteria to the catheter during insertion, increasing the risk of a urinary tract infection.

Choice B rationale:

The nurse lubricates the indwelling urinary catheter. This is a correct procedure as it helps to minimize discomfort and trauma during catheter insertion.

Choice C rationale:

The nurse separates the patient’s labia with her dominant hand. This is also a correct procedure. The nurse should use her non-dominant hand to separate the labia and expose the urethral meatus, and then use her dominant hand to insert the catheter.

Choice D rationale:

The nurse provides perineal care prior to inserting the urinary catheter. This is a correct procedure. Providing perineal care before inserting a urinary catheter is important to reduce the risk of introducing bacteria into the urinary tract. It’s part of maintaining strict aseptic technique during insertion.

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A nurse is caring for a school-age child suffering from respiratory failure due to pneumonia. Which position should the nurse recommend for maximum lung expansion?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is gathering information from a patient who has been experiencing diarrhea for several days. What symptoms should the nurse anticipate?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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A nurse is caring for a school-age child suffering from respiratory failure due to pneumonia.
Which position should the nurse recommend for maximum lung expansion?