A perioperative nurse is caring for a postoperative patient. The patient has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should
1 address the patient’s increased risk for wh
...
A perioperative nurse is caring for a postoperative patient. The patient has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should
1 address the patient’s increased risk for what complication?
A) Acute respiratory distress syndrome (ARDS)
B) Atelectasis
C) Aspiration
D) Pulmonary embolism
Ans: B
Feedback:
A shallow, monotonous respiratory pattern coupled with immobility places the patient at an increased risk of developing atelectasis. These specific factors are less likely to result in pulmonary embolism or aspiration. ARDS involves an exaggerated inflammatory response and does not normally result from factors such as immobility and shallow breathing.
A critical-care nurse is caring for a patient diagnosed with pneumonia as a surgical complication. The nurse’s assessment reveals that the patient has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage
2. the patient to do?
A) Increase oral fluids unless contraindicated.
B) Call the nurse for oral suctioning, as needed.
C) Lie in a low Fowler’s or supine position.
D) Increase activity.
Ans: A
Feedback:
The nurse should encourage hydration because adequate hydration thins and loosens pulmonary secretions. Oral suctioning is not sufficiently deep to remove tracheobronchial secretions. The patient should have the head of the bed raised, and rest should be promoted to avoid exacerbation of symptoms.
The public health nurse is administering Mantoux tests to children who are being
3. registered for kindergarten in the community. How should the nurse administer this test?
A) Administer intradermal injections into the children’s inner forearms.
B) Administer intramuscular injections into each child’s vastus lateralis.
C) Administer a subcutaneous injection into each child’s umbilical area.
D) Administer a subcutaneous injection at a 45-degree angle into each child’s deltoid. Ans: A
Feedback:
The purified protein derivative (PPD) is always injected into the intradermal layer of the inner aspect of the forearm. The subcutaneous and intramuscular routes are not utilized.
The nurse is caring for a patient who has been in a motor vehicle accident and the care team suspects that the patient has developed pleurisy. Which of the nurse’s assessment
4. findings would best corroborate this diagnosis?
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