A nurse in a critical care unit is caring for a client who is postoperative following a right pneumonectomy. After extubation from the ventilator, in which of the following positions should the client be placed?

Prone

SemiFowler's

Sims

On the nonoperative side

Answer and Explanation

The Correct Answer is B

The correct answer is: d. On the nonoperative side

Choice A: Prone

Reason: Placing a patient in the prone position (lying face down) after a pneumonectomy is generally not recommended. This position can compromise respiratory function by restricting chest expansion and increasing the risk of respiratory complications. Additionally, it can place undue pressure on the surgical site, potentially leading to complications such as impaired wound healing or increased pain.

Choice B: Semi-Fowler’s

Reason: The Semi-Fowler’s position (head of the bed elevated to 30-45 degrees) is often used to promote lung expansion and reduce the risk of aspiration. While it can be beneficial for general postoperative care, it is not the optimal position for a patient who has undergone a pneumonectomy. This position does not specifically address the need to prevent fluid accumulation in the remaining lung.

Choice C: Sims

Reason: The Sims position (lying on the side with one leg bent) is typically used for procedures such as enemas or to facilitate drainage of oral secretions. It is not suitable for a postoperative pneumonectomy patient because it does not provide the necessary support to the remaining lung and can increase the risk of fluid shifting to the nonoperative side.

Choice D: On the nonoperative side

Reason: Placing the patient on the nonoperative side is the correct position. This position helps to prevent fluid from accumulating in the remaining lung and reduces the risk of complications such as mediastinal shift or respiratory distress. By positioning the patient on the nonoperative side, gravity helps to keep the remaining lung expanded and functional.

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Correct Answer is B

Explanation

Choice A reason: Eliciting the gag reflex is not a valid way to assess cranial nerve III. The gag reflex is a protective mechanism that prevents choking or aspiration by triggering a contraction of the pharyngeal muscles when the back of the throat is stimulated. The gag reflex is mediated by cranial nerves IX and X, not III.

Choice B reason: Checking the pupillary response to light is a reliable way to assess cranial nerve III. The pupillary response to light is a reflex that causes the pupil to constrict when exposed to bright light and dilate when exposed to dim light. This reflex helps to regulate the amount of light that enters the eye and protects the retina from damage. The pupillary response to light is controlled by cranial nerve III, which innervates the sphincter pupillae muscle that constricts the pupil.

Choice C reason: Observing for facial symmetry is not a relevant way to assess cranial nerve III. Facial symmetry is the degree of similarity between the two halves of the face. Facial symmetry can be affected by various factors, such as genetics, aging, or facial nerve palsy. Facial nerve palsy is a condition that causes weakness or paralysis of the muscles that control facial expression. Facial nerve palsy is caused by damage to cranial nerve VII, not III.

Choice D reason: Testing visual acuity is not a sufficient way to assess cranial nerve III. Visual acuity is the ability to see fine details and distinguish objects at a distance. Visual acuity depends on various factors, such as the clarity of the lens and cornea, the shape of the eyeball, and the function of the retina. Visual acuity is mainly affected by cranial nerve II, which carries visual information from the retina to the brain. Cranial nerve III does not directly influence visual acuity, but it does innervate some of the muscles that move the eye and enable binocular vision.

A. "My wife tries to get me to go to the grocery store, but I don't like to go out much." B. "I am using the modified feeding utensils at every meal. I still spill, but I'm getting better." C. "My greatest pleasure each day is having a few beers every day." D. "I have all the equipment to take a shower, but I prefer a bed bath, because it is easier."

Correct Answer is B

Explanation

Choice A reason: "My wife tries to get me to go to the grocery store, but I don't like to go out much." This statement indicates that the client is not adapting well, as they are avoiding social activities and isolating themselves. The client may have low self-esteem, depression, or anxiety.

Choice B reason: "I am using the modified feeding utensils at every meal. I still spill, but I'm getting better." This statement indicates that the client is adapting well, as they are using adaptive devices and practicing their skills. The client also expresses a positive attitude and a sense of improvement.

Choice C reason: "My greatest pleasure each day is having a few beers every day." This statement indicates that the client is not adapting well, as they are abusing alcohol and possibly selfmedicating. The client may have emotional distress, chronic pain, or addiction.

Choice D reason: "I have all the equipment to take a shower, but I prefer a bed bath, because it is easier." This statement indicates that the client is not adapting well, as they are not using the available resources and opting for a less independent option. The client may have low motivation, poor selfcare, or learned helplessness.

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A nurse in a critical care unit is caring for a client who is postoperative following a right pneumonectomy. After extubation from the ventilator, in which of the following positions should the client be placed?

Nursing Test Bank

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