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. Asking the client about their expectations encourages them to share their feelings and desires regarding end-of-life care, which establishes a foundation for personalized care planning.

B. Offering spiritual support is important but should come after understanding the client’s specific expectations.

C. Family visitation is a supportive option, but understanding the client’s overall desires is more essential.

D. Nonpharmacological pain management is beneficial, but it should be discussed in the context of the client's expressed goals and preferences.

A. A B. B C. C D. D

Correct Answer is C

Explanation

A. This is a sign of a lower motor neuron lesion which result in flaccid paralysis of the muscles on the same side of the lesion. This includes all muscles innervated by the facial nerve, including those controlling the eyebrows.
B. A positive Babinski sign, which is an important neurological examination finding, is identified when there is dorsiflexion of the big toe and fanning of the other toes in response to a stimulus. This reflex is normal in infants but should disappear by the age of 2 years. In adults, the presence of a positive Babinski sign typically indicates an underlying condition affecting the central nervous system, such as a brain or spinal cord injury.
C. A positive Chvostek's sign is an indication of neuromuscular irritability and is typically associated with conditions such as hypocalcemia. It is elicited by tapping the facial nerve in front of the ear, which, if positive, results in twitching of the facial muscles, particularly the mouth and periorbital muscles. In the context of hypomagnesemia, a positive Chvostek's sign may also be observed due to the role of magnesium in neuromuscular function and its interaction with calcium metabolism.
D. A positive Trousseau sign is a clinical indicator of hypocalcemia, which is characterized by carpopedal spasm that occurs when the blood flow to the arm is occluded. This can be elicited by inflating a blood pressure cuff on the patient's arm to a pressure higher than their systolic blood pressure and maintaining it for 2-3 minutes. The sign is considered positive if there is involuntary flexion of the wrist, thumb, and metacarpophalangeal joints, along with the extension of the fingers.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

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.