A one-day post-operative client complains of severe abdominal pain and has shallow respirations at 22/minute. The client is reluctant to perform coughing and deep breathing. Based on the data, the priority problem that the nurse could assign to this patient is:
ineffective gas exchange.
ineffective breathing pattern
activity intolerance.
decreased cardiac function
The Correct Answer is B
Choice A rationale: Ineffective gas exchange is related to respiratory issues but may not be the priority in this case.
Choice B rationale: Ineffective breathing pattern is the priority problem, as evidenced by shallow respirations and reluctance to perform coughing and deep breathing, which can lead to respiratory complications.
Choice C rationale: Activity intolerance is not the priority problem based on the given data.
Choice D rationale: Decreased cardiac function is not the priority problem based on the given data.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: Suctioning is not typically performed as part of routine pulmonary nursing care every eight hours. It is indicated based on the client's clinical need.
Choice B rationale: Suctioning frequency should be determined by the client's condition and physician's orders, not a fixed hourly schedule.
Choice C rationale: Routine coughing and swallowing of sputum do not necessarily warrant suctioning. Suctioning is indicated when the client is unable to manage secretions effectively.
Choice D rationale: Suctioning is appropriate when the client has gurgling respirations and is unable to cough effectively, indicating the need to clear the airway.
Correct Answer is A
Explanation
Choice A rationale: A serum magnesium level of 1.8 mEq/L is lower than the normal range and can be associated with alcohol withdrawal.
Choice B rationale: Potassium level within the normal range is not specifically indicative of alcohol withdrawal.
Choice C rationale: Calcium level within the normal range is not specifically indicative of alcohol withdrawal.
Choice D rationale: Phosphorus level within the normal range is not specifically indicative of alcohol withdrawal.
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