555-Lippincott's Review for Medical-Surgical Nursing Certification, Fifth Edition-Lippincott-1451

340 ❍ Perioperative nursing9. On the first day after thoracotomy, the nurse’s assessment of the patient reveals a temperature of 100° F(37.8° C), a heart rate of 96 beats/minute, blood pressure of 136/86 mm Hg, and shallow respirations of24 breaths/minute, with rhonchi heard at the lung bases. The patient complains of incisional pain. Which nursingaction takes priority? A. Medicating the patient for pain B. Helping the patient out of bed C. Administering ibuprofen (Motrin) as ordered to reduce fever D. Encouraging the patient to cough and deep-breatheCorrect answer: A Although all the interventions are incorporated in this patient’s care plan, relievingpain and making the patient comfortable take priority. Doing so gives the patient the energy and staminato achieve the other objectives.10. Which intervention is most important to include in a nursing care plan for a patient with atelectasis? A. Give oxygen continuously at 3 L/minute. B. Have the patient cough and deep-breathe every 4 hours. C. Have the patient use an incentive spirometer every hour. D. Get the patient out of bed to a chair every day.Correct answer: C Incentive spirometry is used to prevent or treat atelectasis. Performed every hour,it produces deep inhalations that help open the collapsed alveoli. Giving oxygen (Option A) doesn’tencourage deep inhalation. Coughing and deep breathing (Option B) is a good intervention but rarelyresults in as deep an inspiratory effort as incentive spirometry; it should also be performed more frequentlythan every 4 hours. Getting the patient out of bed to a chair (Option D) also helps expand thelungs and stimulate deep breathing, but it’s not as important as incentive spirometry.