the nurse notes that a patient has incisional pain a poor cough effort and scattered rhonchi after a thoracotomy which action should the nurse take f the nurse notes that a patient has incisional pain a poor cough effort and scattered rhonchi after a thoracotomy which action should the nurse take f
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NCLEX RN Prioritization Questions

1. The nurse notes that a patient has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which action should the nurse take first?

Correct answer: Medicate the patient with prescribed morphine.

Rationale: The correct answer is to medicate the patient with prescribed morphine. A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain, which can worsen with deep breathing and coughing. The priority is to address the incisional pain to facilitate effective coughing and deep breathing, which are essential for clearing the airways and preventing complications. Assisting the patient to sit upright, splinting the patient's chest during coughing, and observing the patient using the incentive spirometer are all appropriate interventions to improve airway clearance, but they should be implemented after addressing the incisional pain with medication.

2. A patient states, “I’m not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up.” Which nursing intervention should have the highest priority?

Correct answer: Suicide precautions

Rationale: The highest priority nursing intervention in this scenario should be suicide precautions. The patient's statement indicates suicidal ideation, which poses an immediate risk to their safety. By implementing suicide precautions, the nurse can ensure constant monitoring and intervention to prevent any self-harm. While addressing self-esteem, anxiety, and sleep issues are essential, ensuring the patient's safety by prioritizing suicide precautions is crucial. Self-esteem-building activities, anxiety self-control measures, and sleep enhancement activities are important interventions but should follow the immediate concern of preventing harm from suicidal thoughts.

3. A 75-year-old client, hospitalized with a cerebral vascular accident (stroke), becomes disoriented at times and tries to get out of bed but is unable to ambulate without help. What is the most appropriate safety measure?

Correct answer: Use a bed exit safety monitoring device

Rationale: Option D is the most appropriate safety measure in this scenario. Using a bed exit safety monitoring device allows the client to retain some independence while ensuring that the nursing staff is alerted when assistance is needed. This solution promotes client safety without compromising their autonomy. Option A, restraining the client in bed, can lead to increased agitation, confusion, and a loss of independence. Option B, asking a family member to stay with the client, shifts the responsibility away from the healthcare team. Option C, checking the client every 15 minutes, is not a sufficient safety measure as the client could attempt to get out of bed in the unobserved interval, risking falls and injury.

4. Which of these specific measurements is the best index of a child’s general health?

Correct answer: Height and weight

Rationale: Height and weight are the most accurate measurements to assess a child's general health. These measurements reflect the physical growth and development of the child, indicating overall health status. Choices C and D, head circumference and chest circumference, are important measurements for specific assessments but do not provide as comprehensive an overview of general health as height and weight. Body mass index (BMI) is a calculation based on height and weight, making height and weight more direct and primary indicators of a child's health compared to BMI.

5. A child presents to the emergency department with colicky abdominal pain in the lower right quadrant. What disorder is suspected based on these symptoms?

Correct answer: B: Appendicitis

Rationale: The child's presentation of colicky abdominal pain in the lower right quadrant is classic for appendicitis. Appendicitis typically presents with localized pain that starts near the umbilicus and then shifts to the right lower quadrant. Peritonitis, on the other hand, is characterized by diffuse abdominal pain, tenderness, and guarding, usually resulting from organ perforation or intestinal obstruction. Intussusception is associated with acute, severe abdominal pain and currant jelly-like stools due to intestinal telescoping. Hirschsprung's disease, which lacks ganglion cells in the colon, manifests with symptoms like constipation, abdominal distension, and foul-smelling, ribbon-like stools.

Similar Questions

The family of a child with cerebral palsy (CP) is at risk for difficult parenting issues. Which basis would the nurse conclude as the probable cause for this difficulty?
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While eating in the hospital cafeteria, a nurse notices a toddler at a nearby table choking on a piece of food and appearing slightly blue. What is the appropriate initial action to take?
A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is most appropriate?
To which of the following do the CDC Standard precautions recommendations apply?

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