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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: A respiratory rate of 10 breaths/min is slightly below normal (12-20 breaths/min) but may not necessitate a tracheostomy unless accompanied by other factors like airway obstruction or inability to protect the airway. Tracheostomy is typically reserved for prolonged ventilation needs, not isolated low respiratory rates.
Choice B reason: A client requiring permanent ventilation, such as in chronic neuromuscular diseases or severe lung injury, needs a tracheostomy to provide a stable, long-term airway. Unlike endotracheal tubes, tracheostomies reduce complications like vocal cord damage and improve patient comfort, making them the standard for prolonged mechanical ventilation.
Choice C reason: Dyspnea, or shortness of breath, indicates respiratory distress but does not inherently require a tracheostomy. It may be managed with oxygen or non-invasive ventilation. Tracheostomy is indicated for airway obstruction or prolonged ventilation, not transient symptoms like dyspnea, which can have multiple causes.
Choice D reason: Respiratory acidosis, due to elevated CO2 from hypoventilation, may require ventilatory support but not necessarily a tracheostomy. Non-invasive ventilation or temporary intubation may suffice. Tracheostomy is reserved for long-term airway management, making it less relevant for acute acidosis without evidence of prolonged ventilation needs.
Correct Answer is C
Explanation
Choice A reason: A respiratory rate of 28/min and temperature of 101°F suggest tachypnea and fever, possibly due to infection or inflammation. While concerning, these do not indicate immediate life-threatening issues like acute coronary syndrome. The ABCDE approach prioritizes circulation (chest pain) over respiratory rate, making this a lower priority.
Choice B reason: Difficulty swallowing and nausea may indicate an esophageal issue or infection but are not immediately life-threatening. These symptoms do not compromise airway, breathing, or circulation acutely in the ABCDE framework. Chest pain with diaphoresis suggests a cardiac emergency, which takes precedence due to potential for rapid deterioration.
Choice C reason: Chest pain with diaphoresis is highly suggestive of acute coronary syndrome, such as myocardial infarction, a life-threatening emergency. The ABCDE approach prioritizes circulation, and these symptoms indicate potential cardiac ischemia, requiring immediate assessment, ECG, and intervention to prevent cardiac arrest, making this the highest priority client.
Choice D reason: Blood pressure of 100/60 mm Hg with a painful, swollen wrist suggests a musculoskeletal injury with mild hypotension. While concerning, it is not immediately life-threatening compared to chest pain with diaphoresis, which may indicate acute coronary syndrome. The ABCDE approach prioritizes circulation issues like cardiac events over stable injuries.
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