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 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.
Correct Answer is C
Explanation
Choice A rationale:
Circular turns involve wrapping the bandage around the limb in a continuous circle, with each layer overlapping the previous one. While this technique is effective for securing dressings on cylindrical body parts like the arm or thigh, it's not ideal for joints like the ankle. Circular turns can constrict movement and potentially impair circulation, especially if applied too tightly. Additionally, they don't provide adequate compression for wounds that require it.
Choice B rationale:
Figure-of-eight turns create a cross-over pattern around the joint, resembling the number 8. This technique offers better flexibility and movement compared to circular turns, but it's still not the most appropriate for the ankle. The cross-over pattern can create uneven pressure points and potentially lead to discomfort or even skin irritation. Moreover, it might not provide sufficient compression for wound management.
Choice C rationale:
Spiral turns involve wrapping the bandage diagonally, ascending or descending the limb, with each layer overlapping the previous one by about half its width. This technique is considered the most suitable for bandaging joints like the ankle for several reasons:
Conforms to Joint Contours: Spiral turns naturally mold to the shape of the ankle, providing even pressure distribution and avoiding constriction points. This ensures comfort and maintains proper blood flow.
Allows for Movement: The diagonal pattern accommodates the natural flexion and extension of the ankle joint, allowing for greater mobility without compromising bandage integrity.
Provides Effective Compression: Spiral turns can be applied with varying degrees of compression to suit the needs of the wound and surrounding tissue. This can help control bleeding, reduce swelling, and promote healing.
Easy to Apply and Adjust: Spiral turns are relatively straightforward to apply and can be easily adjusted if needed, making them adaptable to different wound sizes and patient needs.
Choice D rationale:
Recurrent bandaging involves wrapping the bandage back and forth over the same area multiple times, creating a thicker layer. This technique is primarily used for stumps or areas requiring significant padding and absorption. It's not typically used for bandaging joints like the ankle, as it can create excessive bulk and potentially restrict movement.
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