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:

Difficulty maintaining personal hygiene is not typically an early indication of mild Alzheimer's disease. In the early stages, individuals can still manage personal hygiene.

Choice B rationale:

Difficulty handling finances may occur in the later stages of Alzheimer's disease, but it is not an early indication. In the early stages, the person might still manage financial matters.

Choice C rationale:

Difficulty remembering the names of new friends is a common early sign of mild Alzheimer's disease. It reflects the impairment of short-term memory that often occurs in the early stages of the disease.

Choice D rationale:

Difficulty driving to and from familiar places is more likely to be a mid-to-late-stage symptom of Alzheimer's disease. In the early stages, individuals might still drive familiar routes with minimal difficulty.

A. Place the client in a room with negative airflow. B. Remove isolation gown after leaving the client's room. C. Apply ketoconazole to the lesions three times per day. D. Provide the client with eye protection for ultraviolet B light therapy.

Correct Answer is A

Explanation

Answer: A

Rationale:

A) Place the client in a room with negative airflow: Disseminated herpes zoster (shingles) requires airborne precautions because the virus can become aerosolized. A room with negative airflow helps prevent the spread of the virus to other areas, protecting healthcare workers and other patients from infection.

B) Remove isolation gown after leaving the client's room: Isolation gowns should be removed before leaving the client's room to prevent the spread of contaminants to other areas. This intervention is important for infection control but is not specific to the requirement for negative airflow in cases of disseminated herpes zoster.

C) Apply ketoconazole to the lesions three times per day: Ketoconazole is an antifungal medication and is not used for treating herpes zoster, which is caused by a viral infection. Antiviral medications, such as acyclovir, are appropriate for treating herpes zoster lesions.

D) Provide the client with eye protection for ultraviolet B light therapy: Eye protection is necessary during UVB light therapy to protect the eyes, but UVB light therapy is not a standard treatment for disseminated herpes zoster. The priority intervention is to prevent the spread of the infection by using a negative airflow room.

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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

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client for manifestations of mild Alzheimer's disease. Which of the following findings should the nurse expect as an early indication of the disease?

Correct Answer is C

Explanation

A nurse is planning care for a client who has disseminated herpes zoster (shingles). Which of the following interventions should the nurse include?

Correct Answer is A

Explanation

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