Physiological Adaptation Q 14

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Which nursing intervention ensures adequate ventilating exchange after surgery?

  

     A. Remove the airway only when the client is fully conscious

     B. Assess for hypoventilation by auscultating the lungs

     C. Position client laterally with the neck extended

     D. Maintain humidified oxygen via nasal cannula

    

    

Correct Answer: C. Position client laterally with the neck extended

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Positioning the client laterally with the neck extended does not obstruct the airway so that drainage of secretions and oxygen and carbon dioxide exchange can occur. This position promotes oxygenation via maximum chest expansion and is implemented during events of respiratory distress. Do not let the client slide down; this causes the abdomen to compress the diaphragm, which could cause respiratory change.

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Option A: The client should be weaned first before removing the airway. Weaning from mechanical ventilation is the process of reducing ventilatory support, ultimately resulting in a patient breathing spontaneously and being extubated. This process can be achieved rapidly in ?80% of patients when the original cause of the respiratory failure has improved.

Option B: Assessing hypoventilation through the lungs would provide inadequate results. Changes in the respiratory rate and rhythm are early signs of possible respiratory distress. As moving air in and out of the lungs becomes more difficult, the breathing pattern changes to include the use of accessory muscles to increase chest excursions.

Option D: Oxygen may be maintained after surgery but this might be inadequate. The key is that the client receives oxygenation support at all times until mechanical ventilation is no longer required.

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