A nurse is caring for a client who is 24 hr postoperative. Which of the following interventions should the nurse take to reduce the risk of atelectasis?

Administer morphine intermittent IV bolus every 2 hr to the client.

Turn the client from side to side every 4 hr.

Provide the client with nasotracheal suctioning for 15 to 20 seconds at a time.

Instruct the client to hold the inhaled breath for 2 to 5 seconds with incentive spirometer use.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Administering morphine intermittent IV bolus every 2 hours is not a suitable intervention for reducing the risk of atelectasis. While pain management is important postoperatively, morphine can depress respiratory function and increase the risk of atelectasis.

Choice B rationale:

Turning the client from side to side every 4 hours is important for preventing pressure ulcers and promoting comfort, but it is not a specific intervention for reducing the risk of atelectasis.

Choice C rationale:

Providing nasotracheal suctioning for 15 to 20 seconds at a time is not a preventive measure for atelectasis. Suctioning may be necessary for airway clearance in certain situations, but it does not address the root cause of atelectasis.

Choice D rationale:

This is the correct choice. Instructing the client to hold the inhaled breath for 2 to 5 seconds with incentive spirometer use is an effective intervention to reduce the risk of atelectasis. Incentive spirometry helps to expand the lungs and improve ventilation, preventing atelectasis after surgery.

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Correct Answer is C

Explanation

Choice A rationale:

Taking sitz baths can provide comfort but will not directly address the transmission of herpes simplex virus type 2 (HSV-2). It is essential to avoid sexual activity during outbreaks to prevent spreading the infection to a partner.

Choice B rationale:

Cleansing lesions with 1/2 strength peroxide may irritate the affected area and delay healing. The recommended approach is to use gentle soap and water to clean the lesions.

Choice C rationale:

"I will avoid sexual activity until my lesions are healed.”. This statement indicates an understanding of the teaching because HSV-2 is highly contagious during active outbreaks. Avoiding sexual activity during this time is essential to prevent transmitting the virus to a partner.

Choice D rationale:

"I am not contagious once I begin antiviral medication.”. This statement is incorrect as antiviral medications can help manage outbreaks but do not eliminate the risk of transmission entirely. The virus remains contagious until lesions are completely healed.

A. Prepare an endotracheal tube for intubation. B. Insert a plastic oral airway. C. Provide oxygen using a manual resuscitation bag. D. Perform a head-tilt with chin-lift.

Correct Answer is C

Explanation

Choice A rationale:

Preparing an endotracheal tube for intubation is not the first action the nurse should take in this situation. Intubation is an invasive procedure and should be reserved for cases where other, less invasive methods of airway management have failed.

Choice B rationale:

Inserting a plastic oral airway may help maintain the airway in some situations, but it is not the first action to take when the client's airway is obstructing and their oxygen saturation is low.

Choice C rationale:

Providing oxygen using a manual resuscitation bag (bag-valve-mask device) is the correct first action. This allows the nurse to manually assist the client's breathing and deliver oxygen more effectively than just providing supplemental oxygen through a nasal cannula or face mask.

Choice D rationale:

Performing a head tilt with a chin-lift is a basic airway maneuver, but it may not be sufficient in this situation, especially if the airway is completely obstructed. Providing oxygen with a manual resuscitation bag takes precedence.

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A nurse is caring for a client who is 24 hr postoperative. Which of the following interventions should the nurse take to reduce the risk of atelectasis?

Nursing Test Bank

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