The nurse is caring for a patient with shallow respirations and diminished breath sounds following abdominal surgery yesterday.
Which are the appropriate actions of the nurse? (Select all that apply.)
Teach the patient to splint the incision when coughing to minimize pain.
Assist the patient to sit up in the chair and ambulate in the hallway.
Watch the patient use the incentive spirometer and ensure hourly usage.
Dim the lights, provide warm blankets, and maintain a quiet environment.
Maintain patient privacy and use therapeutic touch as desired by the patient.
Correct Answer : A,B,C
Choice A rationale:
Splinting the incision when coughing helps to minimize pain and discomfort, which can encourage deeper breathing and coughing. This is essential because deep breathing and coughing help to clear secretions from the lungs and prevent atelectasis (collapse of lung tissue).
Steps for splinting the incision:
Place a pillow or folded towel over the incision site.
Instruct the patient to apply gentle pressure to the pillow or towel with their hands when coughing or deep breathing. Encourage the patient to relax their abdominal muscles during coughing and deep breathing exercises.
Choice B rationale:
Sitting up in a chair and ambulating promote lung expansion and help to mobilize secretions. This is because gravity assists in moving secretions from the smaller airways into the larger airways, where they can be more easily coughed up.
Additional benefits of sitting up and ambulating: Improved circulation
Decreased risk of pneumonia Enhanced recovery from surgery Choice C rationale:
Using an incentive spirometer hourly helps to increase lung capacity and prevent atelectasis. The device encourages the patient to take slow, deep breaths, which helps to inflate the alveoli (air sacs) in the lungs.
Instructions for using an incentive spirometer:
Sit upright in a chair or bed.
Place the mouthpiece of the spirometer in your mouth and seal your lips around it.
Inhale slowly and deeply through the mouthpiece, aiming to raise the piston inside the device as high as possible. Hold your breath for 3-5 seconds.
Exhale slowly and completely through the mouthpiece.
Repeat the process 10-15 times per hour, or as instructed by your healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","F","G"]
Explanation
Rationale for each choice:
Choice A: Hypovolemia
Impaired perfusion: Hypovolemia, or a decrease in circulating blood volume, leads to reduced blood flow to the wound site. This means that less oxygen and nutrients are delivered to the tissues, which are essential for healing processes like cell growth and collagen synthesis.
Impaired oxygen delivery: Oxygen is crucial for white blood cells to fight infection and for fibroblasts to create new tissue. Hypovolemia can significantly hinder wound healing by reducing oxygen availability at the wound site.
Delayed inflammatory response: The inflammatory phase of wound healing relies on adequate blood flow to deliver immune cells and initiate tissue repair. Hypovolemia can delay this response, leading to prolonged inflammation and delayed healing.
Decreased fibroblast activity: Fibroblasts, the cells responsible for collagen production, require oxygen and nutrients to function effectively. Hypovolemia can impair fibroblast activity, leading to reduced collagen synthesis and delayed wound closure.
Choice B: Poorly controlled blood glucose levels
Impaired immune function: High blood glucose levels impair the function of white blood cells, making the body more susceptible to infections. Infections at the wound site can significantly delay healing.
Impaired collagen synthesis: Hyperglycemia can also impair collagen synthesis, which is essential for wound strength and closure.
Vascular damage: Chronically high blood glucose levels can damage blood vessels, leading to impaired blood flow and oxygen delivery to the wound site, further hindering healing.
Choice C: Protein deficiency
Impaired collagen synthesis: Protein is a crucial building block for collagen, the main structural protein in connective tissue. A lack of protein can lead to reduced collagen production, resulting in delayed wound healing and weaker scar tissue.
Impaired immune function: Protein is also essential for immune cell function. A deficiency can impair the body's ability to fight infections, increasing the risk of wound complications.
Choice D: Adequate hydration
Incorrect: Staying well-hydrated supports the body’s healing process by ensuring proper blood flow and nutrient transport, thus it does not impede wound healing.
Choice E: Routine ambulation
Incorrect: Early ambulation after surgery promotes healing by improving circulation and reducing the risk of complications like blood clots, making it beneficial rather than harmful.
Choice F: Steroid therapy
Immunosuppressive effects: Steroids suppress the immune system, making the body less able to fight infections and hindering the inflammatory phase of wound healing.
Decreased collagen synthesis: Steroids can also decrease collagen synthesis, leading to weaker wound tissue and delayed closure.
Choice G: Obesity
Impaired blood flow: Excess adipose tissue can compress blood vessels, reducing blood flow to the wound site and impairing oxygen and nutrient delivery.
Increased inflammation: Adipose tissue produces inflammatory cytokines, which can prolong the inflammatory phase of wound healing and delay tissue repair.
Higher risk of infection: The folds of skin in obese individuals can create moist environments that are more prone to bacterial growth and infection.
Choice H: Vitamin C supplementation
Incorrect: Vitamin C plays a key role in collagen formation and tissue repair, so it supports rather than hinders wound healing.
Correct Answer is C
Explanation
Choice A rationale:
Burning dried herbs is a form of traditional medicine, not allopathic medicine.
Traditional medicine encompasses a wide range of practices and therapies that have been used for centuries across different cultures.
It often relies on natural substances and processes, such as herbs, acupuncture, and massage, to promote healing and well- being.
While traditional medicine can offer valuable benefits, it's important to note that it's not always based on scientific evidence and its efficacy can vary depending on the specific practice and condition being treated.
Choice B rationale:
Tai chi exercises are a form of complementary and alternative medicine (CAM), not allopathic medicine.
CAM encompasses a diverse group of therapies that are not considered part of mainstream conventional medicine. Tai chi is a mind-body practice that involves gentle, flowing movements and deep breathing.
It has been shown to offer a range of health benefits, including reducing stress, improving balance, and easing pain.
However, it's important to note that tai chi is not a cure-all and should not be used as a substitute for conventional medical care when necessary.
Choice C rationale:
Prescription of antibiotic medication is a hallmark of allopathic medicine.
Allopathic medicine, also known as conventional or Western medicine, is based on the scientific understanding of the body and disease.
It focuses on diagnosing and treating specific diseases or conditions using medications, surgery, or other interventions that have been proven effective through rigorous scientific research.
Antibiotics are a type of medication that specifically targets and kills bacteria.
They are essential for treating bacterial infections, which can cause a wide range of illnesses, from minor skin infections to life- threatening pneumonia.
Choice D rationale:
Manipulation of the spine, also known as chiropractic care, is a form of CAM, not allopathic medicine. Chiropractic care focuses on the musculoskeletal system, particularly the spine.
Chiropractors use manual adjustments to the spine to relieve pain, improve range of motion, and restore function.
While some studies have shown that chiropractic care can be effective for certain conditions, such as lower back pain, it's important to note that it's not a cure-all and should not be used as a substitute for conventional medical care when necessary.
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