The nurse is caring for a patient with shallow respirations and diminished breath sounds following abdominal surgery yesterday.

Which are the appropriate actions of the nurse? (Select all that apply.)

Teach the patient to splint the incision when coughing to minimize pain.

Assist the patient to sit up in the chair and ambulate in the hallway.

Watch the patient use the incentive spirometer and ensure hourly usage.

Dim the lights, provide warm blankets, and maintain a quiet environment.

Maintain patient privacy and use therapeutic touch as desired by the patient.

Answer and Explanation

Correct Answer : A,B,C

Choice A rationale:

Splinting the incision when coughing helps to minimize pain and discomfort, which can encourage deeper breathing and coughing. This is essential because deep breathing and coughing help to clear secretions from the lungs and prevent atelectasis (collapse of lung tissue).

Steps for splinting the incision:

Place a pillow or folded towel over the incision site.

Instruct the patient to apply gentle pressure to the pillow or towel with their hands when coughing or deep breathing. Encourage the patient to relax their abdominal muscles during coughing and deep breathing exercises.

Choice B rationale:

Sitting up in a chair and ambulating promote lung expansion and help to mobilize secretions. This is because gravity assists in moving secretions from the smaller airways into the larger airways, where they can be more easily coughed up.

Additional benefits of sitting up and ambulating: Improved circulation

Decreased risk of pneumonia Enhanced recovery from surgery Choice C rationale:

Using an incentive spirometer hourly helps to increase lung capacity and prevent atelectasis. The device encourages the patient to take slow, deep breaths, which helps to inflate the alveoli (air sacs) in the lungs.

Instructions for using an incentive spirometer:

Sit upright in a chair or bed.

Place the mouthpiece of the spirometer in your mouth and seal your lips around it.

Inhale slowly and deeply through the mouthpiece, aiming to raise the piston inside the device as high as possible. Hold your breath for 3-5 seconds.

Exhale slowly and completely through the mouthpiece.

Repeat the process 10-15 times per hour, or as instructed by your healthcare provider.

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Correct Answer is ["A","B","C","F","G"]

Explanation

Rationale for each choice:

Choice A: Hypovolemia

Impaired perfusion: Hypovolemia, or a decrease in circulating blood volume, leads to reduced blood flow to the wound site. This means that less oxygen and nutrients are delivered to the tissues, which are essential for healing processes like cell growth and collagen synthesis.

Impaired oxygen delivery: Oxygen is crucial for white blood cells to fight infection and for fibroblasts to create new tissue. Hypovolemia can significantly hinder wound healing by reducing oxygen availability at the wound site.

Delayed inflammatory response: The inflammatory phase of wound healing relies on adequate blood flow to deliver immune cells and initiate tissue repair. Hypovolemia can delay this response, leading to prolonged inflammation and delayed healing.

Decreased fibroblast activity: Fibroblasts, the cells responsible for collagen production, require oxygen and nutrients to function effectively. Hypovolemia can impair fibroblast activity, leading to reduced collagen synthesis and delayed wound closure.

Choice B: Poorly controlled blood glucose levels

Impaired immune function: High blood glucose levels impair the function of white blood cells, making the body more susceptible to infections. Infections at the wound site can significantly delay healing.

Impaired collagen synthesis: Hyperglycemia can also impair collagen synthesis, which is essential for wound strength and closure.

Vascular damage: Chronically high blood glucose levels can damage blood vessels, leading to impaired blood flow and oxygen delivery to the wound site, further hindering healing.

Choice C: Protein deficiency

Impaired collagen synthesis: Protein is a crucial building block for collagen, the main structural protein in connective tissue. A lack of protein can lead to reduced collagen production, resulting in delayed wound healing and weaker scar tissue.

Impaired immune function: Protein is also essential for immune cell function. A deficiency can impair the body's ability to fight infections, increasing the risk of wound complications.

Choice D: Adequate hydration

Incorrect: Staying well-hydrated supports the body’s healing process by ensuring proper blood flow and nutrient transport, thus it does not impede wound healing.

Choice E: Routine ambulation

Incorrect: Early ambulation after surgery promotes healing by improving circulation and reducing the risk of complications like blood clots, making it beneficial rather than harmful.

Choice F: Steroid therapy

Immunosuppressive effects: Steroids suppress the immune system, making the body less able to fight infections and hindering the inflammatory phase of wound healing.

Decreased collagen synthesis: Steroids can also decrease collagen synthesis, leading to weaker wound tissue and delayed closure.

Choice G: Obesity

Impaired blood flow: Excess adipose tissue can compress blood vessels, reducing blood flow to the wound site and impairing oxygen and nutrient delivery.

Increased inflammation: Adipose tissue produces inflammatory cytokines, which can prolong the inflammatory phase of wound healing and delay tissue repair.

Higher risk of infection: The folds of skin in obese individuals can create moist environments that are more prone to bacterial growth and infection.

Choice H: Vitamin C supplementation

Incorrect: Vitamin C plays a key role in collagen formation and tissue repair, so it supports rather than hinders wound healing.

A. Side effect B. Therapeutic effect C. Adverse reaction D. Toxicity

Correct Answer is C

Explanation

Choice A rationale:

Side effect: A side effect is an effect of a drug that is secondary to the main intended effect. It is usually predictable and may be either beneficial or harmful. However, constipation is not a common or expected side effect of iron supplements. It is more likely to be an adverse reaction.

Choice B rationale:

Therapeutic effect: The therapeutic effect is the intended effect of a drug, the one that is desired to treat the condition. In this case, the therapeutic effect of the iron supplement would be to increase the patient's iron levels. Constipation is not the desired effect of the iron supplement, so it is not a therapeutic effect.

Choice C rationale:

Adverse reaction: An adverse reaction is an unwanted or harmful reaction to a drug that is not necessarily predictable. It can range from mild to severe. Constipation is a common adverse reaction to iron supplements. It is thought to be caused by the iron binding to undigested food in the intestines, making it harder to pass stool.

Choice D rationale:

Toxicity: Toxicity refers to a poisonous or harmful effect of a drug. It is usually caused by taking too much of a drug or by a drug interacting with another drug or substance. Constipation is not a sign of iron toxicity. Iron toxicity can cause symptoms such as nausea, vomiting, abdominal pain, and diarrhea.

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The nurse is caring for a patient with shallow respirations and diminished breath sounds following abdominal surgery yesterday.Which are the appropriate actions of the nurse? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A postoperative abdominal surgery patient has been admitted to the surgical floor. The nurse is aware that wound healing is delayed due to complications. Which conditions would prevent normal wound healing at the surgical site? (Select all that apply.)

Correct Answer is ["A","B","C","F","G"]

Explanation

A patient develops constipation after taking a daily iron supplement prescribed by the physician. Which term best describes the patient’s reaction to the supplement?

Correct Answer is C

Explanation

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The nurse is caring for a patient with shallow respirations and diminished breath sounds following abdominal surgery yesterday.

Which are the appropriate actions of the nurse? (Select all that apply.)