The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion?
Frequent change of position
Antibiotics
Oxygen humidification
Chest physiotherapy
The Correct Answer is A
A. Frequent change of position:
Frequent changes in position help prevent pooling of secretions and promote lung expansion. This simple and cost-effective measure is important in preventing complications related to immobility, such as pneumonia and atelectasis. It aids in maintaining optimal respiratory function.
B. Antibiotics: Antibiotics are used to treat bacterial infections and would not directly address the risks associated with decreased mobility.
C. Oxygen humidification: While oxygen therapy may be necessary in some cases, humidification is typically used to prevent drying of mucous membranes and is not a primary intervention for preventing complications of decreased mobility.
D. Chest physiotherapy: Chest physiotherapy involves techniques to mobilize respiratory secretions and may be indicated in specific situations. However, it is not as simple and cost-effective as frequent changes in position.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "The test will provide a detailed profile of the heart’s electrical activity."
This statement is inappropriate because transesophageal echocardiography (TEE) primarily provides detailed images of the heart's structure, such as the valves and chambers, rather than focusing on the heart's electrical activity. The assessment of electrical activity is typically associated with electrocardiography (ECG or EKG) rather than echocardiography.
B. "I will need to start an IV in your arm before the test."
This statement is appropriate. It is common for medical procedures, including TEE, to require an intravenous (IV) line for administration of medications or fluids during or after the procedure.
C. "Your throat may be a little sore after the exam."
This statement is appropriate. TEE involves inserting a probe through the esophagus, and it is common for patients to experience a sore throat afterward due to the presence of the probe.
D. "You will need to refrain from eating and drinking 6-8 hours before this test."
This statement is appropriate. It is standard practice to ask patients to fast for a specific period before TEE to minimize the risk of complications, such as aspiration, during the procedure.
Correct Answer is B
Explanation
A. The development of chronic obstructive pulmonary disease (COPD)
Explanation: The signs and symptoms described, including crackles, orthopnea, S3 heart sound, cough with pink, frothy sputum, and low pulse oximetry, are more indicative of heart failure than COPD.
B. The development of left-sided heart failure
Explanation: This is the correct answer. The signs and symptoms, such as crackles, orthopnea, and cough with pink, frothy sputum, are characteristic of left-sided heart failure. The S3 heart sound is often associated with increased ventricular filling pressures.
C. The development of right-sided heart failure
Explanation: The presented signs and symptoms are more consistent with left-sided heart failure. Right-sided heart failure is often associated with peripheral edema, hepatomegaly, and jugular venous distension.
D. The development of cor pulmonale
Explanation: Cor pulmonale is typically associated with right-sided heart failure due to chronic lung disease. The signs and symptoms described are more indicative of left-sided heart failure.
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