A patient diagnosed with lung carcinoma is scheduled for a left pneumonectomy.
Which nursing intervention should be prioritized in the immediate postoperative period?
Application of anti-embolism stockings.
Use of the incentive spirometer.
Assessment of the chest tube and pleur-evac.
Repositioning the patient in bed.
The Correct Answer is C
Choice A rationale
While the application of anti-embolism stockings can be beneficial in preventing deep vein thrombosis in postoperative patients, it is not the most prioritized nursing intervention in the immediate postoperative period for a patient who has undergone a left pneumonectomy. The immediate postoperative period after a pneumonectomy is critical for monitoring and managing potential complications such as respiratory distress, hemorrhage, and bronchopleural fistula.
Choice B rationale
The use of the incentive spirometer is an important nursing intervention for postoperative patients to promote lung expansion and prevent atelectasis. However, in the immediate postoperative period following a pneumonectomy, the priority is to monitor for complications and ensure the stability of the patient.
Choice C rationale
Assessment of the chest tube and pleur-evac is the most prioritized nursing intervention in the immediate postoperative period for a patient who has undergone a left pneumonectomy. After a pneumonectomy, a chest tube is placed to drain air, blood, and fluid from the pleural space to allow the remaining lung to re-expand. It is crucial to monitor the chest tube system for proper functioning and to assess for complications such as excessive bleeding, infection, or pneumothorax.
Choice D rationale
Repositioning the patient in bed is a standard nursing intervention in postoperative care to enhance comfort, promote lung expansion, and prevent complications such as pressure ulcers and deep vein thrombosis. However, it is not the most prioritized intervention in the immediate postoperative period following a pneumonectomy, where monitoring for respiratory complications and ensuring the stability of the patient are paramount.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
The use of a Passy Muir speaking valve can be important for communication, but it is not the highest priority for discharge teaching.
Choice B rationale
Having the phone number of the healthcare provider to report complications is important, but it is not the highest priority. The patient needs to know how to prevent and recognize complications first.
Choice C rationale
While having emergency personal identification that the patient is unable to speak is important, it is not the highest priority. The patient’s immediate post-operative needs should be addressed first.
Choice D rationale
The ability to perform tracheostomy care is the highest priority for discharge teaching. This is a new and critical skill that the patient must learn to prevent complications, maintain the airway, and manage their own care at home.
Correct Answer is ["A","B","E"]
Explanation
Choice A rationale
Viral pharyngitis can sometimes lead to serious complications such as peritonsillar abscess. Symptoms of this condition include drooling and inability to fully open the mouth. Therefore, patients should be advised to contact a healthcare provider immediately if they experience these symptoms.
Choice B rationale
Viral pharyngitis is contagious and can be spread through saliva. Therefore, patients should be advised to avoid sharing drinks or eating utensils with others to prevent the spread of the infection.
Choice C rationale
Antibiotics are not effective against viral infections, including viral pharyngitis. Therefore, taking prescribed antibiotics on time and not missing doses is not relevant in the context of viral pharyngitis.
Choice D rationale
Checking the body for skin rash twice daily is not typically necessary for patients with viral pharyngitis. While some viruses can cause a rash, it is not a common symptom of viral pharyngitis.
Choice E rationale
Drinking at least 2-3 liters of fluid per day unless contraindicated can help soothe a sore throat and prevent dehydration, which can occur if the patient has a fever or is not eating well due to the sore throat.
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