To increase both the respiratory and circulatory functions of a nonresponsive client, what is the most important intervention for the nurse to perform?

Massage the client's bony areas every hour

Encourage the client to deep breathe and cough every hour

Provide tube feedings every two hours

Change the client's position every two hours

Answer and Explanation

The Correct Answer is B

B. Deep breathing and coughing exercises help to maintain lung expansion and prevent atelectasis (collapse of lung tissue), clear secretions from the airways, which can reduce the risk of respiratory infections like pneumonia, improve oxygenation and ventilation-perfusion matching in the lungs. Additionally, deep breathing exercises can stimulate circulation indirectly by improving oxygenation and gas exchange, which can benefit circulatory function.

A. Massaging bony areas can help prevent pressure ulcers (bedsores) in immobile patients, but it does not directly improve respiratory or circulatory functions. While skin integrity is important, it does not address the physiological needs of respiratory and circulatory systems.

C. While nutrition is important for overall health, especially in a nonresponsive client who may not be able to feed themselves orally, tube feedings primarily address nutritional needs and do not directly impact respiratory or circulatory functions. They are important for preventing malnutrition and supporting recovery, but they do not specifically target the goals of improving respiratory or circulatory functions.

D. Changing positions regularly is crucial for preventing complications such as pressure ulcers and maintaining skin integrity. It can also aid in improving circulation by relieving pressure on vulnerable areas and promoting blood flow. Proper positioning can optimize respiratory function by preventing pooling of secretions and improving lung ventilation. Additionally, positional changes encourage movement of the diaphragm and chest wall, which aids in ventilation and gas exchange.

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Correct Answer is A

Explanation

A. Negligence in nursing refers to the failure to provide care that meets established standards, resulting in harm to the patient. In this case, if the nurse failed to monitor vital signs as per hospital policies and this failure led to complications for the post-operative client, it could constitute negligence. Negligence involves breaching the duty of care owed to the patient, causing harm that could have been reasonably prevented.

B. Nonmaleficence is the principle of doing no harm. While it is an ethical principle guiding healthcare practice, it does not justify or excuse negligence. Negligence involves a failure to uphold the duty of care owed to the patient, resulting in harm due to substandard practice.

C. A misdemeanor typically refers to a lesser criminal offense. Negligence in healthcare generally does not rise to the level of a criminal offense like a misdemeanor unless there is gross negligence or willful misconduct. In most cases, negligence leading to harm is addressed through civil litigation rather than criminal charges.

D. While negligence can certainly be considered unethical behavior in the context of healthcare, negligence itself is a legal concept related to professional malpractice rather than solely an ethical breach. Ethical violations may involve different aspects of professional conduct not directly related to negligence, such as breaches of confidentiality or conflicts of interest.

Correct Answer is ["1705"]

Explanation

To calculate the cumulative fluid intake for the client from 3 p.m. to 11 p.m., convert all measurements to the same unit and then sum them up.

First, convert ounces to milliliters (1 ounce = 29.5735 ml). The tea is 4 ounces, which is approximately 118 ml, and the soda is 6 ounces, approximately 177 ml.

Add all the liquid intake: chicken broth (120 ml) + tea (118 ml) + ice cream (assumed to be 240 ml for 1 cup) + soda (177 ml) + water (550 ml) + half the volume of ice chips (as half the volume of ice chips is water, so 250 ml). The total intake is 120 + 118 + 240 + 177 + 550 + 500= 1705 ml.

Since the intake and output are calculated at 2200, and the client has not consumed anything after 2115, the cumulative fluid intake for the shift is 1705 ml.

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To increase both the respiratory and circulatory functions of a nonresponsive client, what is the most important intervention for the nurse to perform?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse fails to monitor vital signs in accordance with the policy's of the hospital for a post- operative client. As a result, complications occur. On what basis might a lawsuit be successful? The nurse:

Correct Answer is A

Explanation

Correct Answer is ["1705"]

Explanation

The nurse assesses an open wound that is over the area of the client's greater trochanter. What finding would indicate to the nurse that this is a Stage IV pressure injury?

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