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Exam NCLEX-RN topic 4 question 61 discussion

Actual exam question from Test Prep's NCLEX-RN
Question #: 61
Topic #: 4
[All NCLEX-RN Questions]

A client is having a pneumonectomy done today, and the nurse is planning her postoperative care. Nursing interventions for a postoperative left pneumonectomy would include:

  • A. Monitoring the chest tubes
  • B. Positioning the client on the right side
  • C. Positioning the client in semi-Fowler position with a pillow under the shoulder and back
  • D. Monitoring the right lung for an increase in rales
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Suggested Answer: D 🗳️
(A) Chest tubes are usually not necessary in a pneumonectomy because there is no lung to re-expand on the operative side. (B) The pneumonectomy client should be positioned on the back or operated side because the sutured bronchial stump may open, allowing fluid to drain into the unoperated side and drown the client. (C) The client should not have a pillow under the shoulder and back because of the subscapular incision. (D) Rales are commonly heard over the base of the remaining lung, but an increase could indicate circulatory overload and therefore should be closely monitored.

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