A client is unable to take a deep breath and does not want to get out of bed due to chest tube discomfort. To increase the client's compliance with ambulation and deep breathing, the nurse should:

Administer pain medication before ambulation

Tell the patient the importance of lung expansion

Arrange a care schedule to provide rest periods

Teach the patient how to use an incentive spirometer

Answer and Explanation

The Correct Answer is A

Choice A reason: Chest tube discomfort can significantly limit deep breathing and ambulation, increasing atelectasis risk. Administering pain medication reduces discomfort, enabling the patient to perform deep breathing exercises and ambulate, which promote lung expansion and prevent complications like pneumonia. Pain control directly enhances compliance with these critical activities.

Choice B reason: Educating the patient about lung expansion’s importance may improve understanding but does not address the physical barrier of pain. Pain limits the ability to perform deep breathing and ambulation, making education alone insufficient. Pain management is needed first to enable compliance with these respiratory and mobility interventions.

Choice C reason: Arranging rest periods supports patient recovery but does not directly address pain, the primary barrier to deep breathing and ambulation. While rest is important, it does not facilitate the active participation required for lung expansion or mobility, which are critical to prevent respiratory complications in chest tube patients.

Choice D reason: Teaching incentive spirometer use promotes lung expansion but is ineffective if pain prevents deep breathing. The chest tube’s discomfort limits the patient’s ability to use the device effectively. Pain management must precede teaching to ensure the patient can perform the necessary respiratory exercises without discomfort hindering compliance.

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Correct Answer is A

Explanation

Choice A reason: Full-thickness burns destroy all skin layers, leading to scar tissue formation. Without joint alignment and mobility, scar tissue can tighten, causing contractures that limit movement. Maintaining joint alignment through positioning and therapy prevents these deformities, preserving function and reducing the risk of permanent joint immobility in burn recovery.

Choice B reason: Wound breakdown occurs due to infection or poor healing in burns but is not directly related to joint alignment. Maintaining alignment prevents contractures, not wound integrity issues. Wound breakdown is managed with infection control and dressings, making this complication unrelated to the goal of joint positioning.

Choice C reason: Heterotopic ossification involves abnormal bone growth in soft tissues, sometimes seen in severe burns, but it is not prevented by joint alignment. It results from prolonged immobility or trauma, not directly from burn scarring. Joint alignment targets contractures, making this an incorrect complication for the stated goal.

Choice D reason: Neuropathy in burns may result from nerve damage or compression but is not primarily prevented by joint alignment. Maintaining alignment focuses on preventing scar tissue contractures, not neurological complications. Neuropathy management involves pain control and monitoring, not positioning, making this unrelated to the care plan’s goal.

A. Oxygen saturation of 88% on room air B. Respiratory rate of 26 breaths/min C. Use of accessory muscles to breathe D. Arterial pH of 7.28

Correct Answer is D

Explanation

Choice A reason: Oxygen saturation of 88% in COPD is low but may be baseline for severe disease. It warrants oxygen therapy but is not the most urgent finding. Arterial pH of 7.28 indicates acute respiratory acidosis, a life-threatening complication requiring immediate ventilatory support to correct CO2 retention and acid-base imbalance.

Choice B reason: A respiratory rate of 26 breaths/min indicates tachypnea, common in COPD exacerbation, but is not immediately life-threatening. It reflects respiratory effort to compensate for hypoxia. Arterial pH of 7.28 suggests acute acidosis from CO2 retention, requiring urgent intervention like non-invasive ventilation, making tachypnea a lower priority.

Choice C reason: Accessory muscle use indicates increased work of breathing in COPD exacerbation, signaling distress but not immediate danger. It reflects compensatory efforts for airway obstruction. Arterial pH of 7.28 indicates severe acidosis, a life-threatening condition requiring urgent ventilatory support, making muscle use less critical in this scenario.

Choice D reason: Arterial pH of 7.28 in a COPD exacerbation indicates acute respiratory acidosis due to CO2 retention from hypoventilation. This life-threatening imbalance can lead to coma or cardiac arrest if uncorrected. Immediate intervention, such as non-invasive ventilation, is needed to restore pH and CO2 levels, making this the priority finding.

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A client is unable to take a deep breath and does not want to get out of bed due to chest tube discomfort. To increase the client's compliance with ambulation and deep breathing, the nurse should:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While developing a care plan for a client with full thickness burns, the nurse determines an appropriate goal is to maintain alignment of joints. The goal is to prevent which of the following complications associated with full thickness burns?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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