A nurse is reinforcing preoperative teaching with a client about how to turn, cough, and deep breathe. Which of the following statements by the client indicates an understanding of the teaching?
"This can help prevent nausea."
"This can help prevent pneumonia."
"I should do this every 4 hours."
"I should do this to keep my heart from beating too fast."
The Correct Answer is B
A. "This can help prevent nausea." Turning, coughing, and deep breathing exercises are not primarily aimed at preventing nausea. These exercises are designed to maintain lung function and prevent respiratory complications.
B. "This can help prevent pneumonia." Correct. Turning, coughing, and deep breathing exercises are essential postoperative activities that help prevent the development of pneumonia by promoting lung expansion, clearing mucus, and preventing atelectasis.
C. "I should do this every 4 hours." The frequency of turning, coughing, and deep breathing exercises may vary based on individual client needs and surgical procedures. This statement does not demonstrate a specific understanding of the appropriate timing for these exercises.
D. "I should do this to keep my heart from beating too fast." Turning, coughing, and deep breathing exercises are not directly related to heart rate regulation. They are focused on lung expansion and airway clearance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Restrict the client's visitors to the immediate family: While tuberculosis is a communicable disease, restricting visitors to the immediate family is not a standard precautionary measure. Visitors should be educated about infection control measures and individuals with active tuberculosis
may need to wear masks in certain situations.
B. Assign the client to a negative pressure airflow room: Correct. Clients with active tuberculosis should be placed in a negative pressure airflow room to prevent the spread of infectious airborne particles to other areas of the facility. Negative pressure ensures that air from the room does not flow to other parts of the facility.
C. Discard personal protective equipment outside the client's room: Personal protective equipment (PPE) should be removed and discarded according to facility policy, which often includes removing PPE inside the client's room and properly disposing of it afterward. The nurse should follow standard precautions for infection control.
D. Have the client wear a HEPA mask during transportation throughout the facility: While wearing a HEPA mask may be necessary for clients with tuberculosis, it is not related to the initial admission process. Clients with active tuberculosis may be asked to wear a HEPA mask during transportation when they need to leave their negative pressure room.
Correct Answer is B
Explanation
A. Heart rate 62/min: A heart rate of 62 beats per minute is within the normal range for many adults and may not require immediate reporting unless it is a significant change from the client's baseline.
B. Urine output of 200 mL per 8 hr: Correct. A urine output of 200 mL in 8 hours is considered low and may indicate inadequate kidney perfusion or function. It should be reported to the provider as it could be a sign of renal impairment or dehydration.
C. Pulse oximetry 95% on room air: A pulse oximetry reading of 95% on room air is within the normal range for oxygen saturation in most healthy individuals. It does not require immediate reporting unless the client has a specific condition or baseline that warrants concern.
D. BP 112/76 mm Hg: Blood pressure of 112/76 mm Hg is within the normal range for many adults and may not require immediate reporting unless there are specific concerns related to the client's medical history or condition.
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