The nurse positioning a client after surgery will take into account that the position, which most often predisposes a client to physiologic processes that suppress respiration, is which of the following positions?

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Question 1 of 5

The nurse positioning a client after surgery will take into account that the position, which most often predisposes a client to physiologic processes that suppress respiration, is which of the following positions?

Correct Answer: C

Rationale: Supine position most suppresses respiration post-surgery by limiting diaphragm movement, unlike Fowler's, prone, or side-lying. Nurses adjust this to aid breathing.

Question 2 of 5

Which intervention should the nurse implement to prevent contractures in a patient who is immobile?

Correct Answer: A

Rationale: Frequent position changes prevent contractures in immobile patients by keeping joints mobile and reducing muscle shortening risks. Heat or relaxants offer relief but don't address root immobility, and restraints worsen stiffness. Nurses use this to maintain range of motion, ensuring flexibility and function, a proactive measure against permanent musculoskeletal damage in prolonged stillness.

Question 3 of 5

A nurse is caring for a client receiving high-flow oxygen therapy via a noninvasive positive pressure ventilation (NPPV) device. What is an important nursing intervention for this client?

Correct Answer: C

Rationale: Providing frequent oral care (C) is key with NPPV (e.g., CPAP/BiPAP), as high-flow air dries the mouth, risking sores or discomfort. Q4h SpO2 (A) isn't specific to NPPV. Q15min RR (B) is excessive. 1-2 L/min (D) doesn't apply to NPPV. Oral care enhances comfort, per critical care standards, vital for compliance.

Question 4 of 5

The nurse is to administer digoxin (Lanoxin) elixir to a 6-month-old with a congenital heart defect. The nurse auscultates an apical pulse rate of 100. The nurse should:

Correct Answer: B

Rationale: For a 6-month-old, an apical pulse of 100 beats per minute falls within the normal range (80-150 bpm), indicating it's safe to administer digoxin, a cardiac glycoside for heart defects, without delay. Recording and calling the physician or holding the dose isn't warranted unless the rate drops below 90-100 bpm (per pediatric guidelines). Rechecking post-administration isn't standard unless symptoms arise. Nurses document and proceed, ensuring timely therapy while monitoring for toxicity signs like bradycardia later.

Question 5 of 5

A 5-month-old infant is admitted to the ER with a temperature of 103.6°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:

Correct Answer: B

Rationale: Tenseness of the anterior fontanel is a key sign of bacterial meningitis in a 5-month-old, indicating increased intracranial pressure from infection, alongside fever, irritability, and seizures. Periorbital edema isn't typical, a positive Babinski is normal at this age, and a negative scarf sign relates to tone, not pressure. Nurses assess this bulging fontanel urgently, as it signals worsening inflammation, guiding immediate antibiotic and supportive care to prevent brain damage or death in this critical condition.

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