The nurse emphasizes the importance of deep breathing and coughing exercises post-operatively to prevent complications. Which statement by the client indicates understanding of these exercises?
"I will perform deep breathing exercises only when the pain is minimal."
"I will perform deep breathing exercises every hour while awake."
“I will perform coughing exercises only if I feel short of breath."
"I will avoid deep breathing exercises to prevent straining my incision."
The Correct Answer is B
A. Deep breathing exercises should be performed regularly, regardless of the level of pain. The exercises are crucial for preventing lung complications, and pain management should be addressed so that the client can perform these exercises effectively.
B. This statement reflects a proper understanding of the importance of regular deep breathing exercises. Performing these exercises every hour while awake helps to keep the alveoli open and reduces the risk of atelectasis and pneumonia. Consistent practice is essential for maximizing lung expansion and preventing complications.
C. Coughing exercises should be performed regularly, not just when experiencing shortness of breath. Coughing helps to clear secretions from the airways and prevent their accumulation, which can lead to respiratory infections and other complications.
D. Avoiding deep breathing exercises is not advisable. While there may be some discomfort, deep breathing is essential for lung health post-operatively. The exercises help prevent complications such as atelectasis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While administering 0.9% sodium chloride is an important step to maintain venous access and to help dilute any blood that might still be in the tubing, it is not the first action to take if a transfusion reaction is suspected. This step should occur after the transfusion is stopped and the patient’s safety is ensured.
B. The immediate priority when a transfusion reaction is suspected is to stop the transfusion immediately. This action helps to prevent further exposure to the potentially harmful blood product and mitigates the risk of worsening the reaction. Stopping the transfusion also allows for prompt medical assessment and intervention.
C. Returning the unit of blood to the blood bank is important for investigation and to determine the cause of the reaction, but it should be done after stopping the transfusion and ensuring the client’s safety. The blood bank may require the returned unit to confirm any issues with the blood product.
D. Obtaining a blood sample from the client is crucial for diagnostic purposes and to identify the cause of the reaction, but this should be done after the transfusion has been stopped. The sample may help in diagnosing the type of reaction or in managing it, but it does not address the immediate safety concerns.
Correct Answer is D
Explanation
A. Murmurs are usually related to valve dysfunctions, such as tricuspid or pulmonic valve issues, which may or may not be present in right-sided heart failure.
B. Crackles (or rales) are more commonly associated with left-sided heart failure. They result from fluid accumulation in the lungs (pulmonary congestion) due to the heart's inability to handle the blood returning from the lungs.
C. Chest pain can occur in various cardiac conditions but is not a hallmark symptom of right-sided heart failure. It might be present if there are underlying coronary artery disease issues or other conditions, but it is not directly indicative of right-sided heart failure.
D. Peripheral edema is a classic finding in right-sided heart failure. It results from fluid accumulation in the lower extremities due to the heart's inability to effectively pump blood to the lungs and systemic circulation, causing increased venous pressure and fluid leakage into the tissues.
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