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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. The JP drain helps prevent excessive accumulation of fluid in the wound by actively draining it away. If fluid were to accumulate excessively, it could impair wound healing and increase the risk of infection.

However, the primary purpose of the JP drain is to remove fluid rather than prevent its collection altogether.

B. The JP drain does not directly assess the degree of healing. Its primary function is to drain fluid from the wound to promote healing by preventing fluid accumulation, which could hinder healing. Assessing the degree of healing typically involves visual inspection of the wound by the healthcare provider rather than relying on the drain.

C. This is not the purpose of the JP drain. Healing generally occurs by the gradual migration of cells and tissues to close the wound, which is an internal process. The JP drain assists in the healing process by preventing complications due to fluid accumulation but does not influence healing from outside to inside.

D. While the JP drain itself does not directly prevent the entrance of microorganisms into the wound, it indirectly contributes to infection prevention by removing excess fluid. Accumulated fluid can provide a medium for bacterial growth, potentially leading to infection. By draining fluid effectively, the JP drain helps maintain a cleaner wound environment, reducing the risk of infection.

A. Cardiac B. Gastrointestinal C. Respiratory D. Neurologic

Correct Answer is A

Explanation

A. Hyperkalemia can have significant cardiac effects, potentially leading to life-threatening arrhythmias such as bradycardia, heart block, ventricular tachycardia, or ventricular fibrillation. As potassium levels rise, it affects the electrical conduction of the heart, leading to changes in the ECG (electrocardiogram) and potentially causing fatal arrhythmias.

B. While hyperkalemia primarily affects the cardiovascular system, gastrointestinal symptoms can also occur. These may include nausea, vomiting, abdominal pain, and diarrhea. However, these symptoms are typically less severe compared to cardiac manifestations. Monitoring for gastrointestinal symptoms helps in assessing overall clinical status but is not as critical as assessing cardiac function in the context of hyperkalemia.

C. Respiratory symptoms are not typically associated with hyperkalemia unless severe acid-base disturbances are present. Potassium imbalance itself does not directly affect respiratory function. Therefore, while it is important to assess respiratory status in any client, it is not the priority in the context of hyperkalemia.

D. Hyperkalemia can affect the nervous system, leading to symptoms such as muscle weakness, tingling sensations, and even paralysis in severe cases. However, neurologic symptoms usually occur at higher potassium levels or in the presence of significant electrolyte imbalances affecting nerve function.

Monitoring for neurologic symptoms is important but is generally secondary to assessing cardiac status in the context of approaching severe hyperkalemia.

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To increase both the respiratory and circulatory functions of a nonresponsive client, what is the most important intervention for the nurse to perform?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

It is important for the nurse to ensure that the client's post-operative Jackson-Pratt device is patent because its purpose is to:

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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