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 D
Explanation
Choice A reason: Respiratory depression is not a typical finding associated with anemia; it is more related to respiratory or central nervous system issues.
Choice B reason: Intense abdominal pain is not a common symptom of anemia and would likely indicate other medical conditions.
Choice C reason: Bradycardia, or slow heart rate, is not commonly associated with anemia. Anemia usually causes tachycardia, or a fast heart rate, as the body attempts to compensate for the reduced oxygen-carrying capacity of the blood.
Choice D reason: Dyspnea on exertion is a common symptom of anemia, as the reduced number of red blood cells leads to decreased oxygen delivery to the tissues, causing shortness of breath during activities.
Correct Answer is D
Explanation
Choice A reason: This statement is incorrect because it suggests that higher oxygen levels trigger breathing, which is not the case in hypoxic drive.
Choice B reason: While carbon dioxide levels do influence breathing, this statement is not accurate in the context of hypoxic drive, which is specifically about oxygen levels.
Choice C reason: This choice is incorrect because the client does notice the need to breathe, but the trigger is low oxygen rather than high carbon dioxide levels.
Choice D reason: This is correct. In clients with COPD, chronic high levels of carbon dioxide can lead to a reliance on low oxygen levels to stimulate breathing.
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