Nursing Elites

1. A client is 12 hours postoperative following colon resection. Which of the following interventions should the nurse include in the plan to reduce respiratory complications?

• A. Use incentive spirometer every 4 hours while awake.
• B. Initiate ambulation after discontinuing the NG tube.
• C. Maintain a supine position with an abdominal binder.
• D. Splint the incision to support coughing every 2 hours.

Correct answer: D

Rationale: Following a colon resection surgery, it is essential to support the incision site to reduce the risk of respiratory complications. Splinting the incision helps to minimize pain during coughing, aiding in effective clearing of secretions and preventing respiratory problems. This intervention supports the client's respiratory function postoperatively, promoting optimal recovery.

2. A client is receiving discharge teaching after a total hip replacement. Which statement by the client indicates a need for further teaching?

• A. I will avoid crossing my legs when sitting.
• B. I can sleep on my side as long as I use a pillow between my legs.
• C. I will avoid bending at the waist to pick things up.
• D. I can bend down to tie my shoes after 2 weeks.

Correct answer: D

Rationale: After a total hip replacement, clients should avoid bending at the waist past 90 degrees for at least 6 weeks to prevent dislocation of the hip prosthesis. Bending down to tie shoes involves significant hip flexion and should be avoided during the initial postoperative period to ensure proper healing and reduce the risk of complications.

3. A client is receiving oxygen therapy via nasal cannula. Which finding indicates that the therapy is effective?

• A. The client is able to ambulate in the hall without dyspnea.
• B. The client has a respiratory rate of 24 breaths per minute.
• C. The client's oxygen saturation is 92%.
• D. The client has a productive cough.

Correct answer: A

Rationale: The correct answer is A. Effective oxygen therapy should improve the client's ability to perform activities without dyspnea. This indicates that the oxygen therapy is adequately supporting the client's respiratory needs. An oxygen saturation of 92% may suggest the need for a higher flow rate to improve oxygenation. A respiratory rate of 24 breaths per minute is elevated, indicating potential respiratory distress. A productive cough does not necessarily indicate effective oxygen therapy, as it is a symptom of respiratory irritation or infection, not oxygenation status.

4. During an asthma attack, a healthcare provider is assessing a client for hypoxemia. Which of the following manifestations should the provider expect?

• A. Nausea
• B. Dysphagia
• C. Agitation
• D. Hypotension

Correct answer: C

Rationale: During an asthma attack, hypoxemia can lead to inadequate oxygen supply to the brain, causing symptoms like restlessness, confusion, and agitation. These manifestations result from the body's response to low oxygen levels, aiming to increase oxygenation. Nausea, dysphagia, and hypotension are not typical manifestations of hypoxemia during an asthma attack.

5. A patient is assessing a client who has just been admitted to the emergency department. The client is having difficulty breathing and is using accessory muscles. What action by the nurse is best?

• A. Administer oxygen at 2 liters per minute via nasal cannula.
• B. Assess the client's vital signs including oxygen saturation.
• C. Notify the Rapid Response Team immediately.
• D. Place the client in a high Fowler's position.

Correct answer: D

Rationale: Placing the client in a high Fowler's position is the best action in this situation as it helps to maximize lung expansion, improve breathing, and decrease the work of breathing. This position allows for better chest expansion, improving oxygenation and ventilation for the client in respiratory distress.

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