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."

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. The client has smooth, brown, irregular lesions on the back of each hand – These are likely seborrheic keratoses, which are benign, age-related lesions and do not usually require reporting unless changes suggest malignancy.
B. The client has glossy, white arches around the periphery of the corneas – This is commonly arcus senilis, a normal, benign finding in older adults that does not require intervention.
C. The client reports urinary incontinence – Urinary incontinence can be a sign of underlying issues such as a urinary tract infection or neurological disorder, necessitating further evaluation by the provider.
D. The client reports a decreased sense of taste – A reduced sense of taste is a typical age-related change and does not generally need to be reported unless it is sudden or associated with other symptoms.

A. Ensure a client can use crutches before discharge. B. Check a client's ability to swallow following a stroke. C. Obtain a client's pain rating prior to physical therapy. D. Assist a client to get out of bed after a breathing treatment.

Correct Answer is D

Explanation

A: Incorrect. Ensuring a client can use crutches before discharge requires clinical judgment and skilled assessment, so it should not be delegated to assistive personnel.
B: Incorrect. Checking a client's ability to swallow following a stroke involves assessing the client's airway and potential risk of aspiration, which is a complex nursing task and should not be delegated to assistive personnel.
C: Incorrect. Obtaining a client's pain rating prior to physical therapy requires understanding the client's pain and its management, which should not be delegated to assistive personnel.
D: Correct. Assisting a client to get out of bed after a breathing treatment can be safely delegated to assistive personnel. It involves helping the client move, which is within the scope of their training.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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