Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A. Position the client on the nonoperative side.
Position the client on the nonoperative side: The client should be positioned on the operative side to facilitate expansion of the remaining lung.
B. Monitor respiratory status every 8 hr.
Monitor respiratory status every 8 hr: Postoperative respiratory status should be monitored more frequently than every 8 hours to assess for complications, especially in the initialpostoperative period.
C. Elevate the head of the bed to a 15° angle.
Elevate the head of the bed to a 15° angle: The head of the bed should be elevated to a higher angle (usually 30-45 degrees) to promote optimal lung expansion and reduce the risk ofcomplications such as atelectasis.
D. Encourage the client to splint the incision when coughing.
Encourage the client to splint the incision when coughing: Encouraging the client to splint the incision when coughing helps minimize pain and supports effective coughing to preventcomplications such as atelectasis.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Medsurg Final Proctored Exam. Take the full exam now
Full Explanation
a. Position the client on the nonoperative side: The client should be positioned on the operative side to facilitate expansion of the remaining lung.
b. Monitor respiratory status every 8 hr: Postoperative respiratory status should be monitored more frequently than every 8 hours to assess for complications, especially in the initial
postoperative period.
c. Elevate the head of the bed to a 15° angle: The head of the bed should be elevated to a higher angle (usually 30-45 degrees) to promote optimal lung expansion and reduce the risk of
complications such as atelectasis.
d. Encourage the client to splint the incision when coughing: Encouraging the client to splint the incision when coughing helps minimize pain and supports effective coughing to prevent
complications such as atelectasis.
Similar Questions
A nurse is collecting data from a client prior to the administration of digoxin. Which of the following findings should the nurse report to the provider?
A. Potassium level of 3.0 mEq/L
Potassium level of 3.0 mEq/L: Hypokalemia is a potential adverse effect of digoxin, and apotassium level of 3.0 mEq/L is below the normal range. Low potassium levels can increase the risk of digoxin toxicity.
B. Heart rate of 66/min
Heart rate of 66/min: A heart rate of 66/min is within the normal range. Digoxin is used totreat conditions like atrial fibrillation, and the heart rate should be within an appropriate range for the client's condition.
C. BP of 132/82 mm Hg
BP of 132/82 mm Hg: Blood pressure within the normal range does not require immediate reporting in the context of digoxin administration.
D. Digoxin level of 1.2 ng/ml
Digoxin level of 1.2 ng/ml: The digoxin level of 1.2 ng/ml is within the therapeutic range, and it does not require immediate reporting.
Full Explanation
a. Potassium level of 3.0 mEq/L: Hypokalemia is a potential adverse effect of digoxin, and a
potassium level of 3.0 mEq/L is below the normal range. Low potassium levels can increase the risk of digoxin toxicity.
b. Heart rate of 66/min: A heart rate of 66/min is within the normal range. Digoxin is used to
treat conditions like atrial fibrillation, and the heart rate should be within an appropriate range for the client's condition.
c. BP of 132/82 mm Hg: Blood pressure within the normal range does not require immediate reporting in the context of digoxin administration.
d. Digoxin level of 1.2 ng/ml: The digoxin level of 1.2 ng/ml is within the therapeutic range, and it does not require immediate reporting.
A nurse is collecting data from a client who has a calcium level of 8 mg/dL. Which of the following manifestations should the nurse expect?
A. Tetany
A calcium level of 8 mg/dl is low and can be associated with tetany.
B. Constipation
Constipation: Elevated calcium levels can lead to constipation, as calcium has inhibitory effects on smooth muscle contraction.
C. Negative Chvostek sign
Negative Chvostek sign: A positive Chvostek sign is associated with hypocalcemia, not hypercalcemia.
D. Elevated blood pressure
Elevated blood pressure: Elevated calcium levels are not typically associated with elevated blood pressure. Hypertension is not a common manifestation of hypercalcemia.
Full Explanation
a. Tetany: A calcium level of 8 mg/dl is low and can be associated with tetany.
b. Constipation:This is associated with hypercalcemia as opposed to hypocalcemia
c. Negative Chvostek sign: A positive Chvostek sign is associated with hypocalcemia, not hypercalcemia.
d. Elevated blood pressure: Elevated calcium levels are not typically associated with elevated blood pressure. Hypertension is not a common manifestation of hypercalcemia.
A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions is the priority for the nurse to take?
A. Begin oxygen therapy.
Begin oxygen therapy: Oxygen therapy is the priority intervention for a client with a pulmonary embolism to improve oxygenation and prevent hypoxemia.
B. Start an IV infusion of lactated Ringer’s.
Start an IV infusion of lactated Ringer’s: While fluid resuscitation may be needed, oxygen therapy takes precedence to address the immediate respiratory compromise.
C. Initiate cardiac monitoring.
Initiate cardiac monitoring: Cardiac monitoring is important, but addressing oxygenation is the priority in a client with a pulmonary embolism.
D. Administer IV morphine.
Administer IV morphine: Pain management may be necessary, but the priority is to address the respiratory distress and potential hypoxemia associated with a pulmonary embolism.
Full Explanation
a. Begin oxygen therapy: Oxygen therapy is the priority intervention for a client with a pulmonary embolism to improve oxygenation and prevent hypoxemia.
b. Start an IV infusion of lactated Ringer’s: While fluid resuscitation may be needed, oxygen therapy takes precedence to address the immediate respiratory compromise.
c. Initiate cardiac monitoring: Cardiac monitoring is important, but addressing oxygenation is the priority in a client with a pulmonary embolism.
d. Administer IV morphine: Pain management may be necessary, but the priority is to address the respiratory distress and potential hypoxemia associated with a pulmonary embolism.