Which is the priority nursing diagnosis for a patient with shallow respirations following abdominal surgery?
Ineffective breathing pattern related to incisional pain and anesthesia.
Risk for suffocation related to emotional and cognitive stress after surgery.
Readiness for enhanced comfort related to desire for rest after surgery.
Deficient diversional activity related to boredom from hospitalization.
The Correct Answer is A
Choice A rationale:
Ineffective breathing pattern related to incisional pain and anesthesia is the priority nursing diagnosis for a patient with shallow respirations following abdominal surgery because it addresses the most immediate and life-threatening concern: impaired gas exchange.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
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.
Correct Answer is A
Explanation
Choice A rationale:
Hemorrhoids are swollen veins in the anus and rectum that can cause pain, itching, and bleeding. Sitz baths are a common and effective treatment for hemorrhoids because they can help to:
Reduce inflammation and pain Promote healing
Relax the anal sphincter muscles Cleanse the anal area
Warm water helps to increase blood flow to the area, which can help to reduce swelling and inflammation. The water also helps to soothe and cleanse the irritated tissues.
Sitz baths are typically taken for 10-15 minutes at a time, several times a day. They can be taken in a bathtub or a special sitz bath basin that fits over a toilet seat.
Choice B rationale:
A fractured right arm would not benefit from a sitz bath. Sitz baths are specifically for treating the anal and rectal area.
Choice C rationale:
An abscessed tooth would not benefit from a sitz bath. Sitz baths are specifically for treating the anal and rectal area.
Choice D rationale:
Painful back muscle spasms would not benefit from a sitz bath. Sitz baths are specifically for treating the anal and rectal area.
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