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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Older adult skin is typically more fragile and prone to injury and tears due to decreased elasticity and thinning. Handling the skin gently helps prevent trauma, skin tears, and bruising, promoting skin integrity and comfort.
C. Older adults are more susceptible to temperature changes and may have difficulty regulating body temperature. Appropriate clothing that helps maintain warmth without causing overheating is essential. This includes wearing layers that can be easily adjusted and using fabrics that are breathable and comfortable.
D. Older adult skin tends to be drier due to decreased oil production and reduced hydration levels. Applying moisturizers after bathing helps replenish lost moisture, maintain skin hydration, and prevent dryness and cracking. It is important to choose moisturizers that are suitable for older adult skin and free from irritants.
B. Daily bathing may not be necessary or suitable for all older adults. Excessive bathing can strip the skin of natural oils, leading to dryness and irritation. Instead, the nurse should promote bathing frequency based on individual skin needs, such as using mild, moisturizing cleansers and lukewarm water.
E. Adequate hydration is crucial for maintaining skin health and overall well-being in older adults. While fluid needs vary among individuals, restricting fluid intake to such a low level (1000 mL) is generally not
appropriate unless medically indicated. Older adults should be encouraged to maintain adequate hydration to support skin elasticity, circulation, and overall health.
Correct Answer is A
Explanation
A. Spiritual care is integral to holistic care. Addressing spiritual needs can provide comfort, meaning, and a sense of peace to clients, which can contribute to a reduction in suffering, both physical and emotional. Spiritual distress can exacerbate physical symptoms and affect overall well-being, so addressing these needs can lead to better outcomes.
B. While nurses play a significant role in providing holistic care, including spiritual care, they are not the sole providers. Spiritual care can be provided by chaplains, spiritual counselors, and other healthcare professionals trained in addressing spiritual needs. However, nurses often have frequent and intimate contact with patients, making them well-positioned to assess and address spiritual concerns and to collaborate with other members of the healthcare team to meet these needs.
C. While addressing spiritual needs can contribute to overall well-being and healing, physical healing does not solely depend on meeting spiritual needs. Physical healing involves medical interventions, treatments, and physiological processes. However, addressing spiritual needs can positively impact a client's emotional and psychological state, which can support the overall healing process.
D. Understanding and respecting the client's own beliefs, values, and preferences regarding spirituality is crucial. Each individual may have unique spiritual beliefs and practices that influence their health beliefs and behaviors. The nurse should approach spiritual care with cultural sensitivity and respect for diversity, ensuring that the care provided aligns with the client's beliefs and preferences.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.