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 B
Explanation
Choice A rationale:
Echinacea: It has anti-inflammatory properties and is not typically associated with exacerbating rheumatoid arthritis symptoms. Studies have shown potential benefits in reducing inflammation, including evidence of possible effectiveness for osteoarthritis and rheumatoid arthritis. However, more research is needed to confirm its efficacy and safety in rheumatoid arthritis.
Choice B rationale:
Turmeric:
Curcumin, the active component of turmeric, has both anti-inflammatory and pro-inflammatory effects.
While it has potential benefits for some inflammatory conditions, it can also stimulate the immune system, which could worsen rheumatoid arthritis symptoms in certain individuals.
Studies have shown mixed results, with some indicating potential benefits and others suggesting a possible worsening of symptoms.
Due to this uncertainty, caution is advised, and patients with rheumatoid arthritis should consult with their healthcare providers before using turmeric supplements.
Choice C rationale:
Ginger: It has well-documented anti-inflammatory properties and is not known to exacerbate rheumatoid arthritis symptoms.
Studies have shown ginger to be potentially effective in reducing pain and inflammation in individuals with rheumatoid arthritis.
It is generally considered safe for use in this population.
Choice D rationale:
Valerian: It is a herb primarily used for its sedative and sleep-promoting effects.
It has not been shown to have any significant impact on inflammation or rheumatoid arthritis symptoms. There is no evidence to suggest that it would worsen the condition.
Correct Answer is D
Explanation
Choice A rationale:
STAT orders are urgent and require immediate action. They are typically used for life-threatening situations or when a rapid response is needed to prevent serious harm. In this case, an EKG is important for patients admitted to the cardiac unit, but it is not necessarily an urgent procedure that requires immediate action in all cases.
STAT orders are often given verbally or over the phone, and they are typically written in all capital letters with the word "STAT" prominently displayed.
Examples of STAT orders include medications for cardiac arrest, intubation for respiratory distress, or emergency surgery for a ruptured appendix.
Choice B rationale:
PRN orders are "as needed" orders, meaning they are only carried out when a specific condition or symptom arises. They are not routinely implemented for all patients in a particular unit or setting.
PRN orders allow for flexibility in treatment plans and can help to manage pain, nausea, anxiety, or other symptoms that may fluctuate over time.
Examples of PRN orders include pain medication, anti-nausea medication, or sedatives.
Choice C rationale:
One-time orders are administered only once and are not repeated. They are often used for procedures, diagnostic tests, or medications that are not required on an ongoing basis.
In this case, an EKG is typically a one-time order for patients outside of the cardiac unit, but it becomes a standing order for patients admitted to the cardiac unit due to the increased importance of cardiac monitoring in this setting.
Examples of one-time orders include a chest X-ray, a blood draw, or a dose of antibiotics.
Choice D rationale:
Standing orders are routine orders that are implemented for all patients in a particular unit or setting, unless otherwise specified. They are designed to provide consistent and standardized care, and they often reflect best practices or guidelines for a specific patient population.
Standing orders can help to streamline care processes, reduce the need for individual orders, and ensure that patients receive necessary treatments or interventions without delay.
In this case, the standing order for an EKG upon admission to the cardiac unit ensures that all patients receive this important cardiac assessment, even if the ordering provider does not specifically write an order for it.
Other examples of standing orders in a cardiac unit might include daily weights, regular vital sign checks, or administration of cardiac medications.
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