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 B
Explanation
Choice A reason: A surgical pause is not a commonly used term for this process.
Choice B reason: A time out is a standardized procedure used to verify the correct patient, procedure, and site before surgery begins.
Choice C reason: The preoperative checklist is a broader list of tasks completed before surgery, not the specific pause for verification.
Choice D reason: Time in is not a recognized term for this verification process in the surgical setting.
Correct Answer is D
Explanation
Choice A reason: Applying gentle pressure on the exposed organs is not recommended as it can cause further damage.
Choice B reason: Having the client lie supine with legs straight is part of the correct positioning, but it does not address the need to protect the exposed organs.
Choice C reason: Suctioning secretions from the wound bed is not the immediate priority and can be harmful to the exposed tissues.
Choice D reason: Covering the area with saline-soaked sterile dressings is the correct intervention to keep the organs moist and reduce the risk of organ damage until surgical repair can be performed.
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