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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: While limit-setting is important, it should not be overly strict as it can increase anxiety in patients who are already highly anxious.

Choice B reason: Increasing environmental stimuli may overwhelm a highly anxious patient rather than help them.

Choice C reason: Providing support and a therapeutic milieu offers a safe and structured environment, which can help reduce anxiety and promote healing.

Choice D reason: More freedom can be beneficial, but it must be balanced with the need for a supportive and structured environment for a highly anxious patient.

A. "Will let the patient keep her nail polish on." B. "Should remove her dentures." C. "Can give her dentures to her family." D. "Need a new set of vital signs before surgery."

Correct Answer is A

Explanation

Choice A reason: Nail polish should generally be removed before surgery to allow the pulse oximeter to function properly, but it is not as critical as removing dentures.

Choice B reason: Dentures should be removed before surgery to prevent aspiration and other complications during anesthesia.

Choice C reason: Giving dentures to the family is appropriate after they have been removed, so this does not warrant intervention.

Choice D reason: It is standard procedure to get a new set of vital signs before surgery, so this statement is correct and does not warrant intervention.

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The nurse is assisting in the care of a patient after open-heart surgery. Which action by the other nurse would warrant intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following is a priority when caring for a highly anxious patient?

Correct Answer is C

Explanation

The nurse is assisting a coworker in preparing a patient for surgery. Which statement by the coworker should warrant intervention by the nurse?

Correct Answer is A

Explanation

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