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 A
Explanation
Choice A reason: A positive pregnancy test is a significant concern for a patient preparing for surgery as it can affect the type of anesthesia used and the surgical approach, due to the potential impact on the fetus.
Choice B reason: While a family history of hypertension is important, it is not as immediately concerning as a positive pregnancy test in a patient preparing for surgery.
Choice C reason: A signed advance directive is a document that outlines a patient's wishes regarding medical treatment and is not a concern but rather a part of preoperative preparation.
Choice D reason: A medical history of diabetes is important to consider in surgical patients due to potential complications with wound healing and blood glucose control, but it is not as urgent as confirming pregnancy status before surgery.
Correct Answer is D
Explanation
Choice A reason: Instructing the patient to wear constrictive clothing is incorrect, as it can worsen venous stasis ulcers by impeding blood flow.
Choice B reason: Encouraging the patient to keep legs in a dependent position is not recommended, as elevation helps in reducing venous pressure.
Choice C reason: Frequent ambulation is encouraged to promote blood circulation and prevent stasis.
Choice D reason: Applying compression stockings is a standard care practice to help reduce venous pressure and prevent fluid from pooling in the legs.
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