A nurse is caring for a client following a left lobectomy for lung cancer. The nurse should prioritize which of the following interventions to prevent atelectasis?

Obtain pulse oximetry every two hours.

Teach the client how to use the incentive spirometer.

Instruct the client to practice abdominal breathing.

Encourage oral fluid intake of 2000 mL/24 hours.

Answer and Explanation

The Correct Answer is B

A. Obtain pulse oximetry every two hours: While monitoring oxygen saturation is important in assessing respiratory status, it is not a direct intervention for preventing atelectasis. It is more of an assessment tool to evaluate the effectiveness of interventions aimed at preventing atelectasis.

B. Teach the client how to use the incentive spirometer: Incentive spirometry is a valuable tool for preventing atelectasis postoperatively by promoting deep breathing and lung expansion. Teaching the client how to use the incentive spirometer and encouraging its frequent use can help maintain lung volume and prevent collapse of alveoli.

C. Instruct the client to practice abdominal breathing: While abdominal breathing can be beneficial for promoting relaxation and reducing anxiety, it is not as effective as incentive spirometry in preventing atelectasis postoperatively.

D. Encourage oral fluid intake of 2000 mL/24 hours: Adequate hydration is important for overall health and respiratory function, but it is not specifically targeted at preventing atelectasis. While hydration can help maintain airway secretions thin, it is not the primary intervention for preventing atelectasis after a lobectomy.

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Correct Answer is C

Explanation

A. "I will take my medication even if symptoms improve." This statement indicates understanding of the importance of medication compliance in managing SLE, as symptoms may improve but the disease may still be active.

B. "I will not have my hair dyed or relaxed unless I am in a period of remission." This statement shows awareness of avoiding potential triggers for disease flare-ups during active periods of SLE.

C. "I will sunbathe as often as possible to ensure I get enough vitamin D." Sun exposure can trigger or worsen SLE symptoms, and individuals with SLE are often advised to avoid excessive sun exposure and to use sun protection to minimize flare-ups.

D. "I will report any fever to my healthcare provider immediately." This statement demonstrates understanding of the importance of monitoring for signs of infection or disease flare-ups, which can be common in SLE.

A. The client has circumoral cyanosis. B. The client's heart rate is 86 bpm. C. The client has a pulse ox of 90% on room air. D. The client is lethargic.

Correct Answer is C

Explanation

A. The client has circumoral cyanosis: Circumoral cyanosis, or bluish discoloration around the mouth, is a sign of hypoxia but may not be present in all cases of hypoxemia. Pulse oximetry provides a more objective measurement.

B. The client's heart rate is 86 bpm: Heart rate may be within normal limits even in the presence of hypoxemia, as compensatory mechanisms may not be fully activated.

C. The client has a pulse ox of 90% on room air: A pulse oximetry reading of 90% indicates hypoxemia (oxygen saturation below normal levels), which is a significant finding, especially in a client with COPD who may already have compromised respiratory function.

D. The client is lethargic: Lethargy may occur with severe hypoxemia, but it is a late sign and may not always be present. Monitoring oxygen saturation is more reliable for early detection of hypoxemia.

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A nurse is caring for a client following a left lobectomy for lung cancer. The nurse should prioritize which of the following interventions to prevent atelectasis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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