The nurse is assisting in the care of a patient after open-heart surgery. Which action by the other nurse would warrant intervention?
Providing the patient with a pillow to brace the incision
Instructing the patient to perform deep coughing every 30 minutes
Having the patient sit up and lean forward
Giving pain medication prior to coughing
The Correct Answer is B
Choice A reason: Providing a pillow to brace the incision is a recommended practice to support the incision during coughing or movement.
Choice B reason: Instructing the patient to perform deep coughing every 30 minutes is a standard postoperative care practice to prevent atelectasis.
Choice C reason: Having the patient sit up and lean forward can help with breathing and comfort after surgery.
Choice D reason: Giving pain medication prior to coughing is actually a recommended practice to reduce pain and facilitate effective coughing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The first step should always be to assess the patient's physical state to rule out any immediate life-threatening conditions before proceeding with psychiatric interventions.
Choice B reason: Administering medication may be necessary, but it should not precede an assessment of the patient's vital signs.
Choice C reason: While instructing the patient to sit and breathe deeply can help alleviate symptoms of anxiety, it is not the first action to take before assessing the patient's vital signs.
Choice D reason: Imagery exercises can be helpful for managing anxiety, but they are not the priority before ensuring the patient's physiological stability.
Correct Answer is C
Explanation
Choice A reason: Direct communication with the surgeon can provide the patient with reassurance and specific information about the surgery, which may alleviate fears.
Choice B reason: Offering spiritual support may be helpful, but it does not directly address the patient's concern about the surgery itself.
Choice C reason: Providing statistics may be reassuring, but it may not fully address the patient's individual fears.
Choice D reason: Recommending analgesics only addresses pain management and not the patient's expressed fear regarding the surgery.
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