A one-day post-operative client complains of having a lot of mucus in his throat and is having a difficult time moving it to his mouth so he can spit it out. The client is reluctant to perform coughing and deep breathing due to pain. Based on the data, the priority problem that the nurse could assign to this patient is:

activity intolerance.

ineffective breathing pattern.

ineffective gas exchange.

ineffective airway clearance.

Answer and Explanation

The Correct Answer is D

D. This refers to the inability to clear secretions or obstructions from the respiratory tract to maintain airway patency. Based on the client's complaint of difficulty moving mucus from the throat to the mouth for expectoration, ineffective airway clearance is the priority problem. The client's reluctance to cough and deep breathe due to pain further exacerbates this issue, as effective airway clearance is crucial for preventing complications such as respiratory infections or atelectasis post-operatively.

A. Activity intolerance refers to insufficient physiological or psychological energy to endure or complete required or desired daily activities. In the case of a one-day post-operative client experiencing difficulty clearing mucus, activity intolerance is not the priority problem. The client's main issue is related to respiratory function and airway clearance rather than overall activity tolerance.

B. This refers to abnormal respiratory rate, depth, or rhythm that does not provide adequate ventilation. While the client's complaint of difficulty moving mucus and reluctance to cough or deep breathe suggests some respiratory discomfort, the main issue appears to be the inability to effectively clear airway secretions rather than an overall ineffective breathing pattern.

C. This refers to the inability to exchange oxygen and carbon dioxide across the alveolar-capillary membranes. While mucus in the throat can potentially affect gas exchange if it obstructs airflow significantly, the client's primary complaint is about difficulty clearing mucus rather than signs and symptoms of inadequate oxygenation or ventilation.

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Correct Answer is ["A","B","C","E"]

Explanation

A. Clients with dementia often experience cognitive decline, which can affect their ability to navigate their surroundings safely. Modifying the environment can include simplifying the layout, reducing clutter, using clear signage, and ensuring adequate lighting to enhance orientation and reduce confusion.

B. Communication difficulties are common in dementia. Using short, simple sentences helps clients better understand instructions and information. It reduces confusion and frustration, promoting effective communication and cooperation during care.

C. Maintaining independence and dignity is crucial for clients with dementia. Allowing them to participate in Activities of Daily Living (ADLs) to the extent possible helps preserve their functional abilities, boosts their self-esteem, and promotes a sense of control over their environment.

E. Providing choices within a structured framework can empower clients with dementia. It allows them to maintain some control over their daily routine and decisions, thereby enhancing their sense of autonomy and reducing agitation or resistance to care.

D. This is not an appropriate intervention. Social interaction, including visits from family members, can have significant emotional and psychological benefits for clients with dementia. It can help reduce feelings of isolation, improve mood, and provide reassurance and familiarity.

A. Massage the client's bony areas every hour B. Encourage the client to deep breathe and cough every hour C. Provide tube feedings every two hours D. Change the client's position every two hours

Correct Answer is B

Explanation

B. Deep breathing and coughing exercises help to maintain lung expansion and prevent atelectasis (collapse of lung tissue), clear secretions from the airways, which can reduce the risk of respiratory infections like pneumonia, improve oxygenation and ventilation-perfusion matching in the lungs. Additionally, deep breathing exercises can stimulate circulation indirectly by improving oxygenation and gas exchange, which can benefit circulatory function.

A. Massaging bony areas can help prevent pressure ulcers (bedsores) in immobile patients, but it does not directly improve respiratory or circulatory functions. While skin integrity is important, it does not address the physiological needs of respiratory and circulatory systems.

C. While nutrition is important for overall health, especially in a nonresponsive client who may not be able to feed themselves orally, tube feedings primarily address nutritional needs and do not directly impact respiratory or circulatory functions. They are important for preventing malnutrition and supporting recovery, but they do not specifically target the goals of improving respiratory or circulatory functions.

D. Changing positions regularly is crucial for preventing complications such as pressure ulcers and maintaining skin integrity. It can also aid in improving circulation by relieving pressure on vulnerable areas and promoting blood flow. Proper positioning can optimize respiratory function by preventing pooling of secretions and improving lung ventilation. Additionally, positional changes encourage movement of the diaphragm and chest wall, which aids in ventilation and gas exchange.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing care for an elderly client who has dementia. Interventions used would include: (SELECT ALL THAT APPLY)

Correct Answer is ["A","B","C","E"]

Explanation

To increase both the respiratory and circulatory functions of a nonresponsive client, what is the most important intervention for the nurse to perform?

Correct Answer is B

Explanation

The inexperienced nurse is reassigned to another unit to care for a critically ill client whose care is beyond her capability. What action should the nurse take first?

A client who has had a right-sided below-the-knee amputation is complaining of constant pain in his right ankle. The nurse documents that the client is experiencing what type of pain?

A client's serum potassium level is approaching 7 mEq/L. Which physical assessment would the nurse prioritize based on this serum lab value?

The nurse is providing care for a client in protective environment isolation. Which nursing action is the priority intervention?

When auscultating over the apex of the client's lung field, what breath sound should the nurse expect to hear?

Which example best illustrates the principle of the nurse "knowing" the client? The nurse:

The nurse is assessing the client for the presence of dysuria. The nurse should ask: "Do you:

The nurse prepares to assess the client's radial pulse. Which statement made by the nurse reflects a correct understanding of the procedure? "I will: