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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["56"]
Explanation
Calculate the infusion rate in mL/min.
The total volume to be infused is 500 mL.
The infusion time is 90 minutes.
The infusion rate = 500 mL / 90 minutes = 5.5556 mL/min.
Calculate the drip rate in gtt/min.
The drop factor is 10 gtt/mL.
We need to deliver 5.5556 mL/min.
To find the drip rate, we can set up a proportion:
10 gtt / 1 mL = x gtt / 5.5556 mL
Cross-multiplying:
x = 10 gtt/mL x 5.5556 mL = 55.5556 gtt
Round the answer to the nearest whole number.
56 gtt/min.
Correct Answer is B
Explanation
A. Decrease in heart rate: While nitroglycerin can sometimes cause reflex tachycardia (an increase in heart rate) as a compensatory mechanism in response to a decrease in blood pressure, its primary effect is on reducing myocardial oxygen demand through vasodilation. Although heart rate may decrease in some situations due to improved perfusion or as a secondary response to pain relief, a decrease in heart rate is not the most reliable or immediate indicator of effectiveness in this context. The relief of chest pain is a more direct measure of the drug's impact.
B. Relief of chest pain: Nitroglycerin works by dilating blood vessels, which reduces myocardial oxygen demand and improves blood flow to the heart, particularly in cases of acute myocardial infarction (MI). The primary therapeutic goal is to relieve chest pain (angina) and reduce the workload of the heart. Monitoring for relief of chest pain is the most direct and important indicator of the medication's effectiveness. If the chest pain decreases or resolves, it suggests that the medication is helping to alleviate the ischemia caused by the MI.
C. Decrease in cardiac dysrhythmias: Nitroglycerin is not primarily used to treat dysrhythmias, although improved perfusion and reduced myocardial oxygen demand may indirectly reduce the occurrence of dysrhythmias in some cases. However, a decrease in dysrhythmias is not a primary goal of nitroglycerin therapy, and the nurse should not primarily monitor for this outcome. Any dysrhythmias should be managed with other specific interventions if needed.
D. Decrease in blood pressure: Nitroglycerin's vasodilatory effect does lead to a reduction in blood pressure, particularly in patients with high blood pressure or in the context of a myocardial infarction. However, excessive hypotension can be dangerous and may lead to inadequate perfusion of vital organs. The nurse must monitor blood pressure closely to avoid hypotension, but a decrease in blood pressure is not the main goal of therapy. The primary objective is to relieve the chest pain associated with the MI. If blood pressure drops too low, it may indicate a need to adjust the dose or discontinue the nitroglycerin.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.