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Exhibits

Which actions can the nurse do to assist the client in improving their ventilation and oxygenation? Select all that apply.

Positioning the client with the head of the bed elevated

Avoid treating fever with antipyretics

Encourage the client to take breaks from the oxygen mask every few hours

Providing suctioning so the client does not have to cough

Assist the client in ambulating safely

Asking the client to do quick, shallow breaths

Teaching the client to cough at least once an hour

Answer and Explanation

Correct Answer : A,E,G

A. Positioning the client with the head of the bed elevated helps improve lung expansion and facilitates better ventilation and oxygenation, reducing the work of breathing.
B. Avoid treating fever with antipyretics is not appropriate, as managing fever can help reduce metabolic demand and improve overall comfort, which aids in ventilation.
C. Encouraging the client to take breaks from the oxygen mask is not advisable, as consistent oxygen delivery is critical for maintaining adequate oxygen saturation, especially in cases of pneumonia.
D. Providing suctioning so the client does not have to cough may not be necessary; coughing is a natural mechanism to clear secretions and improve airway patency.
E. Assisting the client in ambulating safely promotes lung expansion, enhances circulation, and aids in the mobilization of secretions, contributing positively to ventilation and oxygenation.
F. Asking the client to do quick, shallow breaths is counterproductive, as it can lead to inadequate ventilation and decreased oxygenation; deep breathing is preferred.
G. Teaching the client to cough at least once an hour is essential for clearing secretions and improving lung function, thereby enhancing ventilation and oxygenation.

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Correct Answer is D

Explanation

A. Raising hands above the head may not effectively improve gas exchange and could lead to discomfort in a client with dyspnea.
B. Laying down may not facilitate optimal breathing; instead, sitting upright is generally more effective.
C. Increasing the breathing rate can lead to hyperventilation and does not improve gas exchange.
D. Drawing air in through the nose and exhaling slowly through pursed lips helps maintain positive pressure in the airways, prevents airway collapse, and improves gas exchange by allowing for more effective expiration.

A. Acute pancreatitis. B. Biliary duct obstruction. C. Surgical site infection. D. Hepatorenal failure.

Correct Answer is A

Explanation

A. The symptoms of persistent upper abdominal pain radiating to the back, elevated serum amylase and lipase levels, vomiting, and fever suggest acute pancreatitis, which can occur after cholecystectomy due to potential injury to the pancreas or bile duct obstruction.
B. While biliary duct obstruction can occur postoperatively, the significantly elevated amylase and lipase levels, along with the described symptoms, more strongly indicate pancreatitis.
C. Surgical site infection typically presents with localized symptoms rather than systemic symptoms like elevated amylase and lipase.
D. Hepatorenal failure is unlikely to present with these specific gastrointestinal symptoms and enzyme elevations.

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Exhibits Which actions can the nurse do to assist the client in improving their ventilation and oxygenation? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with emphysema who is mildly dyspneic after ambulation. Which instruction should the nurse provide to the client to improve gas exchange?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

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The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

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Exhibits

Which actions can the nurse do to assist the client in improving their ventilation and oxygenation? Select all that apply.