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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
B. According to Medicare and The Joint Commission guidelines, the use of patient restraints requires a physician's order. The order should specify the reason for the restraint, the type of restraint, and the duration or conditions for its use.
C. Before using restraints, healthcare providers must exhaust all alternative, less restrictive measures to manage the patient's behavior or condition. This could include environmental modifications, reassurance techniques, or pharmacological interventions.
E. Restraints should be removed or released every 2 hours for reevaluation and to provide opportunities for range of motion exercises, toileting, hydration, and skin care. Restraints should not be used continuously without periodic assessment and reevaluation.
A. Punitive measures are not appropriate or effective in the use of patient restraints. Restraints should only be used for medical reasons to ensure patient safety, not as a form of punishment.
D. Inadequate staffing is not a criterion specified for using patient restraints. Restraints should not be used as a substitute for sufficient staffing levels to monitor and manage patient care.
Correct Answer is B
Explanation
B.This formulation is not intended for administration through a gastrostomy tube and could be harmful to the patient. It is essential to consult with a pharmacist or physician to find a suitable alternative that is safe for administration through the gastrostomy tube
A. Ibuprofen is typically administered orally (PO) and is absorbed in the gastrointestinal tract.
C. Levothyroxine is a thyroid hormone replacement medication crucial for maintaining thyroid hormone levels in individuals with hypothyroidism. It is typically administered orally in the morning on an empty stomach to ensure optimal absorption.
D. Liquid formulations are suitable for administration through gastrostomy tubes, as they are generally well-tolerated and absorbed.
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