Which of the following does the nurse implement to prevent postoperative respiratory complications for a patient? (Select all that apply)

Deep breathing and coughing

Incentive spirometry

Leg exercises

Early ambulation

Hand squeezes

Answer and Explanation

Correct Answer : A,B,D

Choice A reason: Deep breathing and coughing exercises help clear the lungs and prevent atelectasis, a common postoperative respiratory complication.

Choice B reason: Incentive spirometry encourages patients to take deep breaths, which can help keep the lungs clear of mucus and prevent pneumonia.

Choice C reason: Leg exercises improve circulation and can help prevent blood clots, which can lead to pulmonary embolism, another serious respiratory complication.

Choice D reason: Early ambulation, or getting the patient moving as soon as possible after surgery, is crucial for preventing respiratory complications by promoting circulation and lung expansion.

Choice E reason: Hand squeezes are not directly related to preventing respiratory complications; they are more associated with preventing circulatory complications.

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Correct Answer is ["A","E"]

Explanation

Choice A reason: A bounding pulse can indicate fluid volume excess, as the heart works harder to pump the increased volume.

Choice B reason: Elevated temperature is not specifically indicative of fluid volume excess and can be related to various conditions.

Choice C reason: Warmth at the IV site may indicate an infection or inflammation, not necessarily fluid volume excess.

Choice D reason: Profuse sweating is not typically a sign of fluid volume excess; instead, it may indicate dehydration or other conditions.

Choice E reason: Crackles in the lungs can indicate fluid overload, especially in the context of excessive IV fluid administration.

A. The client's unconscious need to manipulate others B. The client's delusion that cleaning is necessary C. The client's wish to decrease the time available for interaction with others D. The client's attempt to decrease anxiety

Correct Answer is D

Explanation

Choice A reason: OCD is not characterized by an unconscious need to manipulate others but by anxiety-driven compulsions.

Choice B reason: While clients with OCD may feel a need to clean due to contamination fears, it is not a delusion but rather an obsession that drives the compulsion.

Choice C reason: The repetitive cleaning is not typically a conscious choice to decrease social interaction but a compulsion to alleviate anxiety.

Choice D reason: Repetitive behaviors in OCD, such as cleaning, are attempts to decrease the anxiety caused by obsessive thoughts.

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Which of the following does the nurse implement to prevent postoperative respiratory complications for a patient? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is receiving IV fluids at 100 mL per hour. Which assessment findings would indicate fluid volume excess? (Select all that apply.)

Correct Answer is ["A","E"]

Explanation

A nurse is collecting data from a client who has obsessive-compulsive disorder (OCD) and observes that the client demonstrates constant repetitive cleaning. The nurse should realize that the client's repetitive behaviors occur due to which of the following?

Correct Answer is D

Explanation

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