The nurse encourages the 84-year-old patient who is recovering from a hip replacement to:
Keep the bed flat to aid in lung expansion.
Cough frequently to make up for the loss of cilia.
Encourage bed rest.
Restrict fluid to prevent pulmonary congestion.
The Correct Answer is B
Choice A rationale
Keeping the bed flat does not necessarily aid lung expansion and can sometimes increase the risk of aspiration in patients with compromised mobility or cognition.
Choice B rationale
Encouraging the patient to cough frequently helps clear secretions from the lungs, compensating for the diminished function of cilia in elderly patients.
Choice C rationale
Encouraging bed rest can lead to complications such as muscle atrophy, decreased lung capacity, and increased risk of pressure ulcers in elderly patients.
Choice D rationale
Restricting fluid intake to prevent pulmonary congestion is not generally recommended unless there is a specific medical condition requiring fluid restriction, as adequate hydration is vital for overall health.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Lowering the mask below the chin for reuse is incorrect because it can cause contamination. Masks should be discarded after each use to prevent the spread of infectious agents.
Choice B rationale
Removing the mask first before other PPE is incorrect because it can lead to self-contamination. The mask should be removed after the gown and gloves, following proper PPE removal protocols.
Choice C rationale
Discarding the mask only if it is wet and otherwise folding and storing it for reuse is incorrect. Masks should not be reused once they have been worn as they may harbor infectious agents.
Choice D rationale
Untying the bottom ties first, then the top, and disposing of the mask without touching it is correct because it prevents contamination of the hands and ensures safe disposal.
Correct Answer is B
Explanation
Choice A rationale
Keeping sterile gloved hands in sight, away from unsterile objects, maintains sterility by reducing the risk of accidental contamination.
Choice B rationale
Opening the wrapper of a sterile pack toward the body, starting with the proximal flap, increases the risk of contaminating the contents of the sterile pack, as the wrapper may touch unsterile clothing.
Choice C rationale
Avoiding coughing, sneezing, or talking near a sterile field is essential as respiratory droplets can introduce contaminants and compromise the sterility.
Choice D rationale
Avoiding reaching across or above a sterile field with bare hands or arms prevents contamination from skin cells or clothing particles that might fall into the field.
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