The nurse is caring for a client who is 3 hours post-operative following a right lobectomy for lung cancer. The client has shallow respirations at a rate of 14/minute with guarding of the operative site. The breath sounds are diminished throughout the left lung field. The nurse assigns the highest priority to which intervention to prevent acute respiratory failure?

Encourage the daily use of the incentive spirometer

Assisting the client with ambulation in the hallway

Increasing the chest tube suction to 44 mmHg

Assessing for adequate pain relief

Answer and Explanation

The Correct Answer is D

A. Encourage the daily use of the incentive spirometer: While the use of an incentive spirometer is important for improving lung expansion and preventing atelectasis, it may not be effective unless the client’s pain is well-managed. If pain is not addressed first, the client may be unable or unwilling to use the incentive spirometer properly, thus delaying recovery and increasing the risk of respiratory complications.

B. Assisting the client with ambulation in the hallway: Ambulation is an important post-operative activity for improving circulation and preventing complications such as deep vein thrombosis (DVT) or pneumonia. However, the priority at this time should be addressing the client's pain and ensuring adequate breathing before attempting more strenuous activities like ambulation. If the client is in pain and not breathing effectively, ambulation could exacerbate respiratory difficulties..

C. Increasing the chest tube suction to 44 mmHg: Increasing chest tube suction is not indicated unless there is evidence of inadequate drainage or a specific complication, such as a pneumothorax or pleural effusion. In this case, the priority is to address the client’s respiratory function, which is more likely to improve with pain relief, deep breathing, and appropriate positioning. Suctioning should only be adjusted if there is a clinical reason such as signs of a pneumothorax or inadequate drainage, which is not indicated by the information provided.

D. Assessing for adequate pain relief: The most urgent intervention in this scenario is ensuring that the client has adequate pain relief. The client’s shallow respirations and guarding of the operative site suggest that pain is inhibiting effective breathing and deep inspiration, which is crucial for preventing atelectasis and improving ventilation. Pain control is essential in promoting optimal respiratory function, as uncontrolled pain can lead to shallow breathing, reduced lung expansion, and compromised gas exchange, all of which can increase the risk of acute respiratory failure. Once pain is managed, the client will be better able to engage in other respiratory interventions

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Resume smoking initially to help manage stress and anxiety:
Smoking is a significant risk factor for cardiovascular disease and can worsen the prognosis after coronary artery bypass graft (CABG) surgery. Smoking increases the risk of coronary artery disease and impairs healing after surgery. Therefore, advising the client to resume smoking, even temporarily, is unsafe and completely contrary to health recommendations for post-CABG care. Smoking cessation should be emphasized as a key part of the recovery process.

B. Consume a high-fat diet to promote weight gain and energy:
A high-fat diet is not recommended for individuals with coronary artery disease, especially after CABG surgery. Consuming a diet high in saturated fats and cholesterol can lead to further plaque buildup in the coronary arteries, increasing the risk of atherosclerosis and cardiac events. After CABG, patients are typically encouraged to follow a heart-healthy diet that is low in saturated fat, high in fiber, and rich in fruits, vegetables, and lean proteins to support overall heart health and recovery.

C. Avoid physical activity and rest as much as possible:
While rest is essential immediately following surgery, complete avoidance of physical activity is not advisable long-term. In fact, early and gradual physical activity is a key component of rehabilitation after CABG surgery. A sedentary lifestyle can increase the risk of complications such as blood clots, muscle weakness, and weight gain, while physical activity helps improve circulation, heart function, and overall recovery. The nurse should encourage the client to gradually resume physical activity according to the guidance of their healthcare provider, often starting with light walking and progressing as tolerated.

D. Continue taking all prescribed medications as directed: Following coronary artery bypass graft (CABG) surgery, it is essential for the client to continue taking all prescribed medications, including antiplatelets, statins, beta-blockers, and any other medications ordered by the healthcare provider. These medications play a critical role in preventing blood clots, controlling blood pressure, reducing cholesterol levels, and preventing future cardiac events. Stopping or altering medications without consulting a healthcare provider could increase the risk of complications or recurrent cardiac events.

A. Apply 4L of nasal oxygen, administer a cough suppressant, and place client on bedrest B. Increase fluid intake, administer antibiotic(s), and facilitate adequate coughing C. Decrease activity, increase bronchodilator use, and encourage pursed lip breathing D. Place in prone position, begin steroid therapy, and monitor glucose levels

Correct Answer is B

Explanation

A) Apply 4L of nasal oxygen, administer a cough suppressant, and place client on bedrest:
This approach is inappropriate for a client with bacterial pneumonia. While oxygen therapy may be necessary for some clients, administering a cough suppressant in this scenario is counterproductive. Pneumonia often leads to the accumulation of secretions, and suppressing the cough would prevent the client from clearing mucus from their airways, potentially worsening the condition. Bedrest is generally indicated, but it should not be the sole intervention.

B) Increase fluid intake, administer antibiotic(s), and facilitate adequate coughing:
This is the most appropriate plan of care. Increasing fluid intake helps to thin the mucus, making it easier to clear from the airways, which is crucial in pneumonia. Antibiotics are necessary to treat the bacterial infection causing pneumonia. Facilitating adequate coughing helps the client expel secretions, reducing the risk of airway obstruction and improving oxygenation. Coarse rhonchi indicate the presence of mucus or secretions, which should be cleared with effective coughing.

C) Decrease activity, increase bronchodilator use, and encourage pursed lip breathing:
Decreasing activity is generally appropriate for a client with pneumonia to reduce fatigue, but increasing bronchodilator use is not typically indicated unless there is underlying bronchospasm, such as in asthma or COPD. Pursed lip breathing can help improve ventilation, but it is more beneficial for clients with obstructive airway diseases, not primarily for those with bacterial pneumonia. Therefore, this option does not address the immediate needs of the client.

D) Place in prone position, begin steroid therapy, and monitor glucose levels:
While prone positioning is helpful in some conditions like acute respiratory distress syndrome (ARDS), it is not routinely used for bacterial pneumonia unless the client has severe hypoxemia and requires advanced respiratory support. Steroid therapy is generally not indicated for bacterial pneumonia unless there is a specific inflammatory component (such as a superimposed condition like asthma or COPD). Monitoring glucose levels may be important in clients on steroid therapy, but this is not a primary concern in the treatment of bacterial pneumonia.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is being discharged following coronary artery bypass graft surgery. Discharge instructions would include:

Correct Answer is D

Explanation

The nurse is providing care to a client admitted with a diagnosis of bacterial pneumonia. On assessment, the client has dry mucous membranes and coarse rhonchi. What nursing interventions would the nurse include in the plan of care?

Correct Answer is B

Explanation

The nurse is providing education for a client diagnosed with myasthenia gravis (MG) taking pyridostigmine. The nurse understands teaching has been effective when the client states, "I will

The nurse is caring for a client with acute respiratory failure who has been placed on bi-level positive airway pressure (BIPAP) for adequate ventilation. The client complains of nausea and begins to vomit. The priority nursing intervention would be:

The physician orders 500 mg PO of medication. The Medication is supplied as a suspension 125 mg/5mL. How many mL will the nurse administer for one dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

The client diagnosed with multiple sclerosis (MS) is at risk for fatigue. Which priority intervention would the nurse implement to address this issue?

The nurse is caring for a client diagnosed with acute respiratory failure as a result of right middle and lower lobe pneumonia. To optimize ventilation and secretion removal the nurse should position the client:

Which nursing intervention is the highest priority for the client who has had an acute anterior wall myocardial infarction?