A nurse is caring for a client at risk for atelectasis. Which independent nursing measure should the nurse prioritize to prevent atelectasis development?
Incentive spirometry
Increase oral fluid intake
Ambulation
Oxygen therapy
The Correct Answer is A
A. Incentive spirometry: This is the most effective independent nursing measure to prevent atelectasis. Incentive spirometry encourages deep breathing and lung expansion, which helps to keep the alveoli open and reduces the risk of collapse. It is particularly beneficial for clients at risk for atelectasis, such as those who have had surgery, are immobile, or have respiratory issues. Regular use of the incentive spirometer promotes optimal lung function and helps prevent the development of atelectasis.
B. Increase oral fluid intake: While maintaining adequate hydration is important for overall health and can help thin secretions, it is not as directly effective in preventing atelectasis as incentive spirometry. Increased fluid intake alone does not promote deep breathing or lung expansion, which are critical in preventing airway collapse.
C. Ambulation: Although ambulation is an important intervention for promoting overall mobility and respiratory function, it may not be as practical for all clients, especially those who are unable to move independently. While getting the client up and moving can help prevent atelectasis, the most immediate and effective measure remains the use of incentive spirometry, which can be performed regardless of the client’s mobility status.
D. Oxygen therapy: While oxygen therapy can help improve oxygenation in clients with respiratory issues, it does not directly prevent atelectasis. Providing supplemental oxygen does not address the need for lung expansion and deep breathing, which are essential in maintaining alveolar patency. Therefore, oxygen therapy should not be prioritized as the primary independent measure to prevent atelectasis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Opening and utilizing supplies that are necessary for the task. The efficiency domain in healthcare quality focuses on minimizing waste, optimizing resource utilization, and reducing unnecessary costs. By ensuring that only necessary supplies are used, healthcare facilities can prevent waste, control expenses, and enhance operational efficiency, making this choice the best representation of the efficiency domain.
B. Working to reduce wait times in the emergency department. Reducing wait times falls under the timeliness domain rather than efficiency. Timeliness ensures that patients receive care without unnecessary delays, improving access to treatment and patient outcomes. While efficiency and timeliness are related, reducing wait times primarily aligns with improving prompt care delivery rather than minimizing waste.
C. Using an interpreter for patients who do not speak the health-care provider's language. This action falls under the equity domain, which ensures that all individuals receive fair and unbiased care regardless of language, socioeconomic status, or cultural background. Providing language services improves access to quality healthcare but does not specifically address efficiency.
D. Utilizing the CAUTI bundle to prevent urinary tract infections when placing indwelling urinary catheters. This initiative falls under the safety domain, which focuses on preventing harm to patients through evidence-based practices. Implementing infection prevention measures improves patient safety but is not directly related to efficiency, which focuses on cost-effectiveness and resource management.
Correct Answer is A
Explanation
A. "I feel frustrated when you interrupt me. It's important for us to take turns speaking during client discussions." This response demonstrates assertive behavior because it expresses the nurse's feelings directly and respectfully while addressing the specific behavior that is problematic. By focusing on "I feel" statements, the nurse communicates personal feelings without blaming or attacking the colleague. This approach encourages a constructive dialogue and promotes a more collaborative working relationship.
B. "If you keep interrupting me, I'll report you to our supervisor for disciplinary action." This response is not assertive; it is more aggressive and threatening. It shifts the focus from the behavior to a punitive action and can escalate conflict rather than fostering a constructive conversation. It may create defensiveness in the colleague and is unlikely to resolve the underlying issue.
C. "You always interrupt me when I'm talking. Can't you see how disrespectful that is?" This response is accusatory and confrontational, which is not assertive behavior. While it addresses the behavior, it does so in a way that may cause the colleague to become defensive or hostile. Effective assertiveness involves expressing feelings and needs without assigning blame or using harsh language.
D. "I can't work with someone who constantly takes over conversations. You need to find another partner." This statement is dismissive and aggressive, effectively shutting down communication rather than encouraging teamwork. It does not allow for resolution or discussion of the behavior, making it counterproductive in promoting effective collaboration. Assertive communication should focus on addressing issues while maintaining a willingness to work together.
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