A nursing student is assessing a postoperative client who has developed bilateral pneumonia. The nursing plan of care includes positioning the client in the semi-Fowler’s position, elevating the head of the bed from 30 degrees to 45 degrees.
What is the rationale for this position?
It facilitates nursing assessments of skin color and temperature.
The client will be more comfortable and have less thoracic pain.
It promotes full expansion of the lung fields.
It increases blood flow to the heart.
The Correct Answer is C
Choice A rationale:
While elevating the head of the bed can make it easier to visualize the patient's face and upper chest, it's not the primary rationale for positioning a patient with pneumonia in semi-Fowler's position.
Skin color and temperature can be assessed in other positions as well, such as supine or side-lying. In cases of pneumonia, prioritizing respiratory function takes precedence over ease of skin assessment. Choice B rationale:
While semi-Fowler's position can offer some comfort, it's not the most comfortable position for all patients, especially those with thoracic pain.
Positions that fully support the back and minimize pressure on the chest, such as side-lying with pillows, may provide better pain relief.
The primary goal in positioning a patient with pneumonia is to optimize respiratory function, not solely to maximize comfort.
Choice C rationale:
Semi-Fowler's position effectively promotes lung expansion due to the following reasons:
Gravity: Elevating the head of the bed allows gravity to assist in pulling the diaphragm downward, creating more space for lung expansion.
Abdominal pressure: The semi-upright position reduces pressure from the abdominal organs on the diaphragm, further facilitating its downward movement and enhancing lung expansion.
Secretion drainage: The inclined position encourages drainage of secretions from the upper airways, preventing their accumulation and potential airway obstruction. This allows for better air entry and gas exchange.
Choice D rationale:
While semi-Fowler's position may slightly increase venous return to the heart, it's not the primary reason for using this position in patients with pneumonia.
Positions that significantly increase venous return, such as Trendelenburg position (head down), are typically used for specific indications like shock or hypotension, not for pneumonia management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["65"]
Explanation
Here are the steps to calculate the flow rate in gtt/min:
Step 1: Calculate the total volume of fluid to be infused.
The order is for 1.5 grams of Ampicillin added to 100 mL of Normal Saline, so the total volume is 100 mL. Step 2: Calculate the number of vials of Ampicillin needed.
Each vial contains 500 mg of Ampicillin, and the order is for 1.5 grams (which is 1500 mg). Therefore, you will need 3 vials of Ampicillin (1500 mg ÷ 500 mg/vial = 3 vials). Step 3: Calculate the total volume of Ampicillin solution.
Each vial contains 10 mL of Ampicillin solution, and you need 3 vials.
Therefore, the total volume of Ampicillin solution is 30 mL (3 vials × 10 mL/vial = 30 mL). Step 4: Calculate the total volume to be infused, including the Ampicillin solution. The total volume is 100 mL of Normal Saline + 30 mL of Ampicillin solution = 130 mL. Step 5: Calculate the infusion time in minutes.
The order is to infuse over 120 minutes.
Step 6: Calculate the flow rate in gtt/min.
Use the formula: Flow rate (gtt/min) = Total volume (mL) × Drop factor (gtt/mL) ÷ Infusion time (min) Plug in the values: Flow rate = 130 mL × 60 gtt/mL ÷ 120 min
Simplify: Flow rate = 7800 ÷ 120
Flow rate = 65 gtt/min
Therefore, the flow rate in gtt/min in which the IV fluid is to flow is 65 gtt/min.
Correct Answer is D
Explanation
Choice A rationale:
Planning is conducted during the initial stage of Lewin's change model, known as the unfreezing phase. This phase involves creating awareness of the need for change, building support, and developing a plan for implementation. It's not part of the refreezing phase.
Choice B rationale:
Change is initiated during the second stage of Lewin's change model, known as the change or transition phase. This phase involves implementing the planned changes, providing training and support, and addressing resistance. It's not part of the refreezing phase.
Choice C rationale:
The need for change is recognized during the unfreezing phase, not the refreezing phase. Recognizing the need for change is a crucial step in initiating the change process, but it's not the focus of the refreezing phase.
Choice D rationale:
Change becomes permanent during the refreezing phase. It involves solidifying the new behaviors and practices that have been implemented during the change phase. This is achieved through various strategies, such as:
Reinforcement of the new behaviors through rewards, recognition, and positive feedback
Integration of the new behaviors into organizational policies, procedures, and structures
Creation of a supportive culture that encourages and sustains the change
Ongoing monitoring and evaluation to ensure that the change is sustained over time
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