A nursing student is assessing a postoperative client who has developed bilateral pneumonia. The nursing plan of care includes positioning the client in the semi-Fowler’s position, elevating the head of the bed from 30 degrees to 45 degrees.
What is the rationale for this position?
It facilitates nursing assessments of skin color and temperature.
The client will be more comfortable and have less thoracic pain.
It promotes full expansion of the lung fields.
It increases blood flow to the heart.
The Correct Answer is C
Choice A rationale:
While elevating the head of the bed can make it easier to visualize the patient's face and upper chest, it's not the primary rationale for positioning a patient with pneumonia in semi-Fowler's position.
Skin color and temperature can be assessed in other positions as well, such as supine or side-lying. In cases of pneumonia, prioritizing respiratory function takes precedence over ease of skin assessment. Choice B rationale:
While semi-Fowler's position can offer some comfort, it's not the most comfortable position for all patients, especially those with thoracic pain.
Positions that fully support the back and minimize pressure on the chest, such as side-lying with pillows, may provide better pain relief.
The primary goal in positioning a patient with pneumonia is to optimize respiratory function, not solely to maximize comfort.
Choice C rationale:
Semi-Fowler's position effectively promotes lung expansion due to the following reasons:
Gravity: Elevating the head of the bed allows gravity to assist in pulling the diaphragm downward, creating more space for lung expansion.
Abdominal pressure: The semi-upright position reduces pressure from the abdominal organs on the diaphragm, further facilitating its downward movement and enhancing lung expansion.
Secretion drainage: The inclined position encourages drainage of secretions from the upper airways, preventing their accumulation and potential airway obstruction. This allows for better air entry and gas exchange.
Choice D rationale:
While semi-Fowler's position may slightly increase venous return to the heart, it's not the primary reason for using this position in patients with pneumonia.
Positions that significantly increase venous return, such as Trendelenburg position (head down), are typically used for specific indications like shock or hypotension, not for pneumonia management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
Choice A rationale:
Oral route anesthetic blocks are not considered regional anesthesia. They are a form of systemic anesthesia, meaning they affect the entire body.
Oral anesthetics are absorbed through the gastrointestinal tract and distributed throughout the bloodstream to reach their target sites in the central nervous system.
They produce a general depressant effect on the brain and spinal cord, leading to sedation, unconsciousness, and analgesia. Examples of oral anesthetics include benzodiazepines, barbiturates, and propofol.
Choice B rationale:
Inhalation anesthetic blocks are also a form of systemic anesthesia.
They are administered through inhalation of vaporized gases or volatile liquids.
These anesthetics rapidly cross the alveolar-capillary membrane in the lungs and enter the bloodstream, where they are transported to the brain and other tissues.
They produce a dose-dependent depression of the central nervous system, resulting in loss of consciousness, analgesia, and muscle relaxation.
Examples of inhalation anesthetics include nitrous oxide, sevoflurane, and isoflurane.
Choice C rationale:
Spinal anesthetic blocks are a type of regional anesthesia that involves injecting a local anesthetic directly into the subarachnoid space of the spinal cord.
This blocks nerve transmission in the spinal cord, resulting in loss of sensation and motor function in the lower half of the body.
Spinal anesthesia is commonly used for surgeries below the waist, such as cesarean deliveries, hip replacements, and knee surgeries.
Choice D rationale:
Epidural anesthetic blocks are another type of regional anesthesia that involves injecting a local anesthetic into the epidural space, which is the area surrounding the spinal cord.
This blocks nerve transmission in the spinal nerves, resulting in loss of sensation and motor function in a specific region of the body.
Epidural anesthesia is commonly used for labor and delivery, as well as for surgeries on the abdomen, pelvis, and lower extremities.
Choice E rationale:
Nerve anesthetic blocks (also known as peripheral nerve blocks) involve injecting a local anesthetic around a specific nerve or group of nerves.
This blocks nerve transmission in the targeted area, resulting in loss of sensation and motor function in a specific part of the body.
Nerve blocks can be used for a variety of surgical procedures, as well as for pain management.
Correct Answer is A
Explanation
Urinary retention is the inability to completely empty the bladder. It is a common symptom of BPH, as the enlarged prostate can press on the urethra and obstruct the flow of urine. This can lead to several characteristic symptoms, including:
Feeling of incomplete bladder emptying: Patients often feel as though they haven't fully emptied their bladder, even after urinating.
Straining to urinate: It may take extra effort to initiate and maintain a urine stream.
Weak urine stream: The force of the urine stream may be noticeably reduced.
Intermittent urine stream: The flow of urine may start and stop repeatedly.
Post-void dribbling: Urine may continue to drip after urination has seemingly ended.
Urinary frequency: The need to urinate frequently, often at night (nocturia).
Urgency: A sudden, compelling need to urinate that may be difficult to postpone.
Bladder pain or discomfort: Pressure or pain in the lower abdomen, often associated with a full bladder. Pathophysiology:
Bladder outlet obstruction: The enlarged prostate physically compresses the urethra, the tube that carries urine from the bladder to the outside of the body. This obstruction makes it difficult for urine to flow freely, leading to incomplete bladder emptying.
Detrusor muscle dysfunction: The detrusor muscle, which forms the bladder wall, may become weakened or overactive due to the constant strain of trying to empty against resistance. This can further impair bladder emptying.
Neurological factors: In some cases, nerve damage or dysfunction may contribute to urinary retention, particularly in men with diabetes or neurological conditions.
Additional insights:
Chronic urinary retention can result in serious complications, such as bladder stones, urinary tract infections, and kidney damage.
Acute urinary retention is a medical emergency that requires immediate catheterization to relieve the bladder and prevent further complications.
Treatment for urinary retention typically involves medications to relax the prostate and bladder muscles, as well as lifestyle modifications such as limiting fluid intake before bedtime. In some cases, surgical intervention may be necessary to reduce the size of the prostate or widen the urethra.
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