The nurse is caring for a 39 year old client who is 4 hours postoperative from general anesthesia. The client's spouse asks why it is important for the client to cough and deep breath. The most appropriate response from the nurse would be:
1. It is important in order to prevent a pulmonary embolism
2. It is important in order to reduce the incidence of postoperative depression
3. It is important in order to reduce the chance of aspiration pneumonia
4. It is important in order to reduce the incidence of mucous plugs
4
Rationale: A pulmonary embolism is cause by a blood clot that has moved to the lungs which blocks a pulmonary artery; turning, ambulation, antiembolic stockings and SCDs are preventive interventions
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A mother is concerned because her 9-year-old boy has developed the habit of twitching his eyes and flipping his hair while communicating with anyone. What is the best nursing response to this parent?
a. "This may indicate that he needs eyeglasses." b. "Children sometimes do these things for attention." c. "This behavior suggests low self-esteem." d. "Tics appear when a child is under stress."
A nurse is administering morphine IM, which was prescribed for a patient reporting severe pain. What should be the nurse's primary assessment focus on to evaluate the patient's response to this drug?
a. Cardiac rhythms for tachycardia b. Respiratory rate for tachypnea c. Increased bowel sounds in the gastrointes-tinal system d. Sedative effects in the neurologic system
Which type of bacteria cause infection when a patient's immune system is impaired?
a. Pathogenic b. Nonpathogenic c. Gram negative d. Opportunistic
The nurse is caring for a small child and needs to obtain vital signs. Which site choice from the nursing assistive personnel (NAP) will cause the nurse to praise the NAP?
a. Ulnar site b. Radial site c. Brachial site d. Femoral site