To increase both the respiratory and circulatory functions of a nonresponsive client, what is the most important intervention for the nurse to perform?
Massage the client's bony areas every hour
Encourage the client to deep breathe and cough every hour
Provide tube feedings every two hours
Change the client's position every two hours
The Correct Answer is B
B. Deep breathing and coughing exercises help to maintain lung expansion and prevent atelectasis (collapse of lung tissue), clear secretions from the airways, which can reduce the risk of respiratory infections like pneumonia, improve oxygenation and ventilation-perfusion matching in the lungs. Additionally, deep breathing exercises can stimulate circulation indirectly by improving oxygenation and gas exchange, which can benefit circulatory function.
A. Massaging bony areas can help prevent pressure ulcers (bedsores) in immobile patients, but it does not directly improve respiratory or circulatory functions. While skin integrity is important, it does not address the physiological needs of respiratory and circulatory systems.
C. While nutrition is important for overall health, especially in a nonresponsive client who may not be able to feed themselves orally, tube feedings primarily address nutritional needs and do not directly impact respiratory or circulatory functions. They are important for preventing malnutrition and supporting recovery, but they do not specifically target the goals of improving respiratory or circulatory functions.
D. Changing positions regularly is crucial for preventing complications such as pressure ulcers and maintaining skin integrity. It can also aid in improving circulation by relieving pressure on vulnerable areas and promoting blood flow. Proper positioning can optimize respiratory function by preventing pooling of secretions and improving lung ventilation. Additionally, positional changes encourage movement of the diaphragm and chest wall, which aids in ventilation and gas exchange.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Isometric exercises typically involve pushing or pulling against a stationary object or surface. This action creates muscle tension without joint movement.
B. Using a trapeze involves lifting the body and is more related to mobility assistance rather than isometric exercise. It typically involves movement and is not considered an isometric exercise.
C. Brisk walking is a cardiovascular exercise that involves movement and does not focus on muscle contraction without movement. It improves cardiovascular fitness and endurance rather than strength through isometric contraction.
D. Active range of motion exercises involve moving joints through their full range of motion using muscle strength. This is different from isometric exercises, which involve static muscle contractions without joint movement.
Correct Answer is A
Explanation
A. The psychomotor domain involves the development of physical skills and the ability to manipulate objects. When the client performs a return demonstration of using the incentive spirometer, they are demonstrating their ability to coordinate their muscles and movements to correctly operate the device. This includes actions such as inhaling deeply, maintaining proper technique, and achieving the desired lung volume.
B The cognitive domain pertains to the acquisition and application of knowledge and intellectual skills. Understanding how the incentive spirometer works, its purpose in improving lung function post-surgery, and the correct technique for using it all fall under cognitive learning. The client must grasp the
Rationale behind using the spirometer to promote effective breathing and prevent complications like atelectasis.
C. Imitation involves observing and copying someone else's actions. In the context of using an incentive spirometer, the initial demonstration by the nurse serves as a model for the client to imitate. After receiving instructions and observing the nurse's demonstration, the client imitates the correct technique during the return demonstration. However, imitation alone does not fully capture the learning domain demonstrated by the client.
D. The affective domain focuses on attitudes, values, beliefs, and emotions. While using the incentive spirometer involves physical and cognitive skills, it also involves motivation and willingness to engage in the activity as prescribed by the healthcare provider. This domain encompasses the client's commitment to following through with spirometer use as part of their recovery and adherence to the healthcare plan.
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