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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A respiratory rate of 28/min is not an indication that the intervention was effective. A normal respiratory rate for an adult at rest is between 12 and 20 breaths per minute. A respiratory rate of 28/min is considered tachypnea, which could be a sign of respiratory distress, not an improvement.
Choice B rationale:
Pink mucous membranes are a good sign. They indicate effective oxygenation and perfusion. When the body is receiving an adequate amount of oxygen, the skin, lips, and mucous membranes can appear pink. This is a positive outcome of oxygen therapy for hypoxia.
Choice C rationale:
A heart rate of 110/min is not an indication that the intervention was effective. A normal resting heart rate for adults ranges from 60 to 100 beats per minute. A heart rate of 110/min is considered tachycardia, which could be a sign of distress or compensation for hypoxia, not an improvement.
Choice D rationale:
Restlessness is not an indication that the intervention was effective. On the contrary, restlessness can be a sign of inadequate oxygenation. When the brain does not receive enough oxygen, a patient can become restless or anxious. Therefore, restlessness is not a positive outcome of oxygen therapy for hypoxia.
Correct Answer is C
Explanation
Choice A rationale:
Dry skin is not typically associated with respiratory alkalosis. Respiratory alkalosis occurs when the levels of carbon dioxide and oxygen in the blood aren’t balanced. It occurs when you breathe too fast or too deep and carbon dioxide levels drop too low. This condition does not directly cause dry skin.
Choice B rationale:
Abdominal pain is not a common symptom of respiratory alkalosis. The condition is usually caused by over-breathing (called hyperventilation) that occurs when you breathe very deeply or rapidly. While it can cause discomfort, it does not typically result in abdominal pain.
Choice C rationale:
Diarrhea is not a direct symptom of respiratory alkalosis. However, the stress or anxiety that can cause hyperventilation and lead to respiratory alkalosis might also upset the digestive system and cause diarrhea. It’s important to note that while stress and anxiety can cause both conditions, they are not a direct result of the respiratory alkalosis itself.
Choice D rationale:
Flank pain is not a symptom of respiratory alkalosis. Flank pain is often associated with kidney problems, not respiratory conditions. Respiratory alkalosis is characterized by symptoms such as dizziness, bloating, feeling light-headed, numbness or muscle spasms in the hands and feet, discomfort in the chest area, confusion, dry mouth, tingling in the arms, heart palpitations, and feeling short of breath.
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