A nurse is assisting with the care of a client.

Exhibits
Which of the following actions should the nurse take to promote the client's respiratory status? Select all that apply.

Encourage the client to splint the abdomen when coughing.

Administer acetaminophen.

Administer ondansetron.

Remind the client to use the incentive spirometer five times per hr.

Encourage the client to cough and deep breathe.

Plan to ambulate the client 30 min after the next analgesic is administered.

Answer and Explanation

Correct Answer : A,D,E,F

A. Splinting the abdomen helps reduce pain during coughing, making it easier for the client to take deep breaths and effectively clear secretions. This is particularly important after abdominal surgery to minimize discomfort and promote effective coughing.

B. While acetaminophen can help with pain relief, it does not directly address the respiratory status of the client. Therefore, it is not a priority action in this context.

C. Ondansetron is effective for managing nausea, but it does not contribute to improving respiratory status directly. It is necessary for comfort, but it is not an action that promotes respiratory function.

D. The incentive spirometer is a valuable tool for encouraging deep breathing, which helps expand the lungs, improve ventilation, and prevent atelectasis (lung collapse). Regular use of the spirometer is crucial, especially in postoperative clients with decreased mobility.

E. Coughing and deep breathing are essential practices to prevent respiratory complications. They help clear secretions and promote lung expansion, which can improve oxygenation and respiratory function.

F. Ambulation is important for improving respiratory status by promoting lung expansion and circulation. It also aids in preventing complications such as deep vein thrombosis (DVT) and pneumonia. Planning ambulation after administering analgesics ensures that the client is more comfortable and able to participate in this activity.

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Correct Answer is A

Explanation

A. In the three-point gait, weight is borne on the unaffected leg while the client moves the crutches and the affected leg together.

B. Crutches should be positioned a few inches in front and to the side of each foot to maintain balance and prevent falls.

C. Holding the arms straight can cause strain; a slight bend at the elbows is ideal.

D. Crutches should not be at the axillae level to prevent nerve damage. There should be a 1–2 inch gap below the armpit.

A. "Drink a glass of milk before bedtime." B. "Watch television in bed." C. "Take a long walk before bedtime." D. "Take a 1-hour nap each day."

Correct Answer is A

Explanation

A. Drinking a glass of milk before bedtime can promote sleep due to the presence of tryptophan, an amino acid that helps induce sleepiness. This is a helpful sleep aid strategy.

B. Watching television in bed can stimulate the brain and disrupt sleep, making it more difficult to fall asleep.

C. Engaging in strenuous exercise, such as a long walk, immediately before bed can make it harder to fall asleep by increasing adrenaline levels.

D. Taking a long nap during the day can disrupt nighttime sleep, especially in older adults.

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Body system	Findings
Neurological	Alert and oriented to person, place, and time: deep tendon reflexes 4+
Musculoskeletal	Generalized weakness with equal bilateral muscle strength and mild leg cramping
Respiratory	Lungs clear
Cardiovascular	Heart rate irregular: Heart rate 95/min
Gastrointestinal	Bowel sounds hyperactive x 4 quadrants

A nurse is assisting with the care of a client. Exhibits Which of the following actions should the nurse take to promote the client's respiratory status? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait. Which of the following instructions should the nurse include?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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A nurse is assisting with the care of a client. Exhibits Which of the following actions should the nurse take to promote the client's respiratory status? Select all that apply.

A nurse is assisting with the care of a client.

Exhibits
Which of the following actions should the nurse take to promote the client's respiratory status? Select all that apply.