Question

The nurse notes that a patient has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which action should the nurse take first?

a. Assist the patient to sit up at the bedside.
b. Splint the patient's chest during coughing.
c. Medicate the patient with the prescribed morphine.
d. Have the patient use the prescribed incentive spirometer.

Answer 1

The nurse should first assist the patient to sit up at the bedside for immediate relief and improved respiratory function. Subsequent measures like pain management and use of an incentive spirometer can follow to further aid recovery.

Step-by-step explanation:

The nurse should first assist the patient to sit up at the bedside, as positioning can greatly impact the patient's ability to breathe effectively and clear secretions. Upright positioning can help reduce pain by taking pressure off the incision site, allow for deeper breaths, and improve the efficiency of a cough. The presence of scattered rhonchi, which are coarse rattling sounds somewhat similar to snoring and usually caused by secretions in bronchial airways, indicates that the patient needs to clear their lungs.

After assisting the patient with positioning, the nurse would likely follow with other supportive measures, such as providing pain relief with prescribed morphine to enable a better cough effort and encouraging the use of an incentive spirometer to promote lung expansion and mucus clearance. While the direct administration of pain medication could also be considered, positioning the patient is a quicker intervention that may provide immediate relief and improvement in respiratory function.