A nurse is caring for a patient who is being treated for acute pain from an episode of pancreatitis. The nurse has identified a nursing diagnosis of Ineffective Breathing Pattern related to pain secondary to effects of surgery. Which intervention should the nurse perform in order to best address this diagnosis?
Position the client supine to facilitate diaphragm movement.
Administer corticosteroids by nebulizer as prescribed.
Perform oral suctioning as needed to remove secretions.
Administer analgesic per orders.
The Correct Answer is D
A. Supine positioning can impair diaphragm movement and worsen breathing; semi-Fowler’s is preferred.
B. Corticosteroids are not typically indicated for this condition.
C. Suctioning may be necessary for secretion management but does not directly address pain-related breathing issues.
D. Administering analgesics reduces pain, allowing improved chest expansion and effective breathing, directly addressing the ineffective breathing pattern caused by pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Brudzinski's sign indicates meningeal irritation, not related to hypocalcemia.
B. Kernig's sign also indicates meningeal irritation.
C. Babinski's sign assesses neurological function but is unrelated to calcium levels.
D. Chvostek's sign is a facial muscle spasm triggered by tapping the facial nerve, a classic sign of hypocalcemia, which can occur after thyroidectomy due to inadvertent removal or damage to the parathyroid glands.
Correct Answer is A
Explanation
A. Clients with ascites often require fluid restriction to help manage fluid overload and prevent worsening of edema and ascites.
B. Saturated fats should generally be limited due to the risk of worsening liver function and cardiovascular disease.
C. Sodium intake should be restricted because sodium promotes fluid retention, worsening ascites.
D. Carbohydrates are not typically restricted in cirrhosis unless there is concurrent diabetes or other specific metabolic issues.
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