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 C
Explanation
Choice A reason: Regression involves reverting to an earlier stage of development when faced with stress, which is not what Marie is doing.
Choice B reason: Repression involves unconsciously blocking out painful thoughts or feelings, which is different from Marie's conscious rationalization of her failure.
Choice C reason: Rationalization is a defense mechanism where an individual justifies an unacceptable behavior or feeling with a logical reason, avoiding the true explanation for the behavior. Marie is rationalizing her failure by blaming the instructor rather than accepting her own role in the outcome.
Choice D reason: Reaction formation involves behaving in a way that is opposite to what one truly feels, which is not applicable in Marie's case.
Correct Answer is B
Explanation
Choice A reason: Permanent mobility impairment is a possible complication, but it is not the most common concern immediately following a closed reduction and cast placement.
Choice B reason:Older adults are at a higher risk for delayed healing of fractures due to factors such as reduced bone density, slower cellular repair mechanisms, and potential comorbidities like diabetes or osteoporosis. While permanent mobility impairment, malalignment, and bone infections are possible complications of fractures, they are less common in routine cases of closed reduction and casting, especially if proper care and follow-up are provided. Delayed healing is a more likely complication due to age-related changes in bone health.
Choice C reason: Malalignment of healed bones is a potential long-term complication, but it is not the immediate concern post-cast placement.
Choice D reason: Bone infections (osteomyelitis) are rare following closed fractures treated with casting, especially when there is no open wound. Infections are more likely with open fractures or surgical interventions.
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