A perioperative nurse is caring for a postoperative patient. The patient has a shallow respiratory
pattern and is reluctant to cough or to begin mobilizing. The nurse should address the patients
increased risk for what complication?
A) Acute respiratory distress syndrome (ARDS)
B) Atelectasis
C) Aspiration
D) Pulmonary embolism - Ans: B
Feedback:
A shallow, monotonous respiratory pattern coupled with immobility places the patient at an
increased risk of developing atelectasis. These specific factors are less likely to result in
pulmonary embolism or aspiration. ARDS involves an exaggerated inflammatory response and
does not normally result from factors such as immobility and shallow breathing.
A critical-care nurse is caring for a patient diagnosed with pneumonia as a surgical complication.
The nurses assessment reveals that the patient has an increased work of breathing due to copious
tracheobronchial secretions. What should the nurse encourage the patient to do?
A) Increase oral fluids unless contraindicated.
B) Call the nurse for oral suctioning, as needed.
C) Lie in a low Fowlers or supine position.
D) Increase activity. - Ans: A
Feedback:
The nurse should encourage hydration because adequate hydration thins and loosens pulmonary
secretions. Oral suctioning is not sufficiently deep to remove tracheobronchial secretions. The
patient should have the head of the bed raised, and rest should be promoted to avoid exacerbation
of symptoms.
The public health nurse is administering Mantoux tests to children who are being registered for
kindergarten in the community. How should the nurse administer this test?
A) Administer intradermal injections into the childrens inner forearms.
B) Administer intramuscular injections into each childs vastus lateralis.
C) Administer a subcutaneous injection into each childs umbilical area.
D) Administer a subcutaneous injection at a 45-degree angle into each childs deltoid. - Ans: A
Feedback:
The purified protein derivative (PPD) is always injected into the intradermal layer of the inner
aspect of the forearm. The subcutaneous and intramuscular routes are not utilized.
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