A nurse is assessing a 2-day postoperative patient following chest surgery. The patient is reluctant to ambulate, has a nonproductive cough, and has crackles at the base of the lung
The nurse determines that the patient is most likely exhibiting symptoms of static pulmonary secretions. What should the nurse's primary interventions for this entail?
A) Send a sputum sample for culture and sensitivity testing.
B) Encourage leg exercises every 2 hours.
C) Turn the patient and encourage deep breathing every 2 hours.
D) Decrease the patient's intake of fluids.
Ans: C
Feedback: When the patient is reluctant to ambulate, has a nonproductive cough, and has crackles at the base of the lung, he is most likely exhibiting symptoms of static pulmonary secretions. The patient should be encouraged to turn every 2 hours and take deep breaths to prevent pneumonia.
You might also like to view...
The nurse coming on shift on the medical unit is taking a report on four patients. What patient does the nurse know is at the greatest risk of developing ESKD?
A) A patient with a history of polycystic kidney disease B) A patient with diabetes mellitus and poorly controlled hypertension C) A patient who is morbidly obese with a history of vascular disorders D) A patient with severe chronic obstructive pulmonary disease
Which of the following would a high hematocrit indicate?
A) inadequate red blood cell production B) excessive production of platelets C) polycythemia vera D) too many white blood cells in circulation E) anemia
Which laboratory value indicates that the epoetin alfa (Procrit, Epogen) therapy is effective?
A. Platelet count has decreased from 80,000 to 50,000. B. Segmented neutrophils outnumber the band neutrophils. C. Serum potassium level has increased from 3.5 to 4.5 mEq/L D. Red blood cell count has increased from 2.2 million to 3.0 million.
What is the person's leadership style?
Identify a colleague whom you consider to be a clinical leader or role model. They do not have to hold a position of designated authority (e.g. Nurse Unit Manager), but they should demonstrate leadership qualities. What will be an ideal response?