A patient and a nurse develop a preoperative teaching plan. In teaching the patient to cough effectively after surgery, the nurse should tell her to practice
a. breathing through her nose, holding her breath, and exhaling slowly.
b. taking three deep breaths and coughing from the chest.
c. inhaling while contracting the abdominal muscles and exhaling while contracting the diaphragm.
d. taking short, frequent panting breaths and coughing from the throat to clear accumulated mucus.
B
Because lung ventilation is vital, the nurse assists the patient to turn, cough, and breathe deeply every 1 to 2 hours until the chest is clear. Having practiced this combination preoperatively, the patient is usually able to adequately remove trapped mucus and surgical gases.
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You are the nurse caring for an elderly Asian-American patient who speaks little English. How would you assess this patient's pain?
A) Make a chart with English on one side and the patient's native language on the other. B) Use the regular 0-to-10 pain scale. C) Base your assessment on objective, physiological data. D) Have a translator come in every time you assess the patient, so you can document what the patient said.
The nurse observes a client exercising extremities through range of motion. This client is performing:
a. passive range of motion. c. hyperextension. b. adduction. d. active range of motion.
The nurse, assessing a patient with a Glasgow Coma Score 4, finds the patient's pupils to be pinpoint and nonreactive to light. The nurse realizes that this assessment finding can be caused by damage to the pons or by
1. opioid drug overdose. 2. metabolic disorders. 3. compression to the oculomotor nerve. 4. recent administration of atropine sulfate.
A nurse has identified a coping problem in a family that recently lost their house and all of their belongings in a fire. The nurse next will assess the family's external support systems. These would include which of the following?
1. Grandparents. 2. The parent's siblings. 3. Local social services agencies. 4. The family's religious leader. 5. The family's communication skills.