The nurse is assisting in the care of a patient after open-heart surgery. Which action by the other nurse would warrant intervention?
Providing the patient with a pillow to brace the incision
Instructing the patient to perform deep coughing every 30 minutes
Having the patient sit up and lean forward
Giving pain medication prior to coughing
The Correct Answer is B
Choice A reason: Providing a pillow to brace the incision is a recommended practice to support the incision during coughing or movement.
Choice B reason: Instructing the patient to perform deep coughing every 30 minutes is a standard postoperative care practice to prevent atelectasis.
Choice C reason: Having the patient sit up and lean forward can help with breathing and comfort after surgery.
Choice D reason: Giving pain medication prior to coughing is actually a recommended practice to reduce pain and facilitate effective coughing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Setting consequences just before the behavior occurs does not provide clear expectations and boundaries for the patient.
Choice B reason: Setting consequences after the behavior is done may not effectively prevent the behavior and can lead to inconsistent enforcement.
Choice C reason: Waiting for complaints before setting consequences can lead to a reactive rather than proactive approach to care.
Choice D reason: Consequences should be clearly communicated when the limit is set to establish clear boundaries and expectations, which is essential in managing patients with personality disorders.
Correct Answer is D
Explanation
Choice A reason: Thinking/content of thought refers to the logical process of thought and coherence, not directly to the experience of reality.
Choice B reason: Mood and affect pertain to the emotional state and its expression, not the perception of reality.
Choice C reason: Judgment involves decision-making abilities and the evaluation of situations, not the perception of reality.
Choice D reason: Perception is the component that deals with how a person experiences reality, including any hallucinations or delusions they may have.
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