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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
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.
Correct Answer is C
Explanation
Choice A rationale:
Increasing the intake of high-fiber foods is not relevant to managing dry mouth caused by benztropine. While fiber is essential for digestive health, it does not directly address the issue of dry mouth.
Choice B rationale:
Chewing sugarless gum can be helpful in promoting saliva production, but in Parkinson's disease, it can exacerbate swallowing difficulties and increase the risk of aspiration.
Choice C rationale:
Moistening the mouth with lemon-glycerin swabs is the appropriate recommendation. Lemon-glycerin swabs can help lubricate the mouth and provide relief from dryness, which is a common side effect of benztropine, an anticholinergic medication.
Choice D rationale:
Rinsing the mouth with nystatin is used to treat oral candidiasis (thrush), a fungal infection, and is not relevant to managing dry mouth caused by benztropine.
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