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 B

Explanation

Choice A reason: While patients with HbA1c levels below 6% are generally considered to have good glycemic control, this does not guarantee they will be free from complications.

Choice B reason: Diabetes complications often involve vascular issues, affecting both large (macrovascular) and small (microvascular) blood vessels, leading to a range of complications such as cardiovascular disease and neuropathy.

Choice C reason: Chronic hypoglycemia can lead to various health issues, but it is not typically classified as a long-term complication of diabetes. Instead, it is a risk associated with diabetes management, particularly with insulin use.

Choice D reason: Both Type 1 and Type 2 diabetics are at risk for complications. Tight glycemic control can reduce the risk, but it does not eliminate it, and Type 1 diabetics are not necessarily at the greatest risk.

A. Tumor in situ, no invasion of other tissues. B. Distant metastasis to other sites. C. Abnormal cells present, has spread into nearby tissues. D. No abnormal cells.

Correct Answer is B

Explanation

Choice A reason: Tumor in situ refers to a tumor that has not invaded surrounding tissues, which is not indicative of stage IV cancer.

Choice B reason: Stage IV cancer is characterized by distant metastasis, meaning the cancer has spread to other sites away from the primary location.

Choice C reason: While the spread into nearby tissues indicates progression, it does not necessarily mean stage IV unless there is distant metastasis.

Choice D reason: The presence of no abnormal cells would not be consistent with any stage of cancer.

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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

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