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 B

Explanation

Choice A rationale:

A defined area of cool, boggy skin is not indicative of a stage 2 pressure injury. Stage 2 pressure injuries involve partial-thickness skin loss, usually appearing as a shallow open ulcer with a red-pink wound bed, without slough or bruising.

Choice B rationale:

A shallow crater involving the epidermis is characteristic of a stage 2 pressure injury. It presents as a partial-thickness skin loss with the loss of the epidermis, and the wound may be superficial and appear as an abrasion, blister, or shallow ulcer.

Choice C rationale:

The reddened area that does not blanch is more indicative of an early-stage pressure injury (Stage 1). In Stage 1, the skin remains intact, but there is non-blanch-able erythema indicating damage to the skin and underlying tissue.

Choice D rationale:

Undermining or tunneling of the skin is not specific to stage 2 pressure injuries. These features may be observed in more advanced stages of pressure injuries, such as stages 3 and 4, where there is full-thickness skin loss with damage to the subcutaneous tissue and underlying structures.

A. Administer oxygen. B. Administer opioids. C. Administer whole blood. D. Elevate the head of the bed to 30°. E. Keep the client NPO.

Correct Answer is ["A","B","D"]

Explanation

Choice A rationale:

The nurse should administer oxygen to the client experiencing a sickle cell crisis. Sickle cell crisis can cause vaso-occlusion, leading to tissue hypoxia and pain. Administering oxygen helps to improve tissue oxygenation and relieve symptoms.

Choice B rationale:

Administering opioids is appropriate for managing the severe pain associated with a sickle cell crisis. Opioids are effective analgesics that can help alleviate the acute pain experienced by the client.

Choice C rationale:

Administering whole blood is not typically indicated for a sickle cell crisis. Whole blood transfusion is reserved for specific indications, such as severe anemia or acute blood loss, but it is not a standard treatment for sickle cell crisis pain.

Choice D rationale:

Elevating the head of the bed to 30° can improve oxygenation and reduce the workload on the respiratory system, which is beneficial for clients experiencing a sickle cell crisis. It helps to optimize lung expansion and alleviate hypoxia.

Choice E rationale:

Keeping the client NPO (nothing by mouth) is not necessary in a sickle cell crisis. There is no indication that the client cannot tolerate oral intake, so allowing them to eat and drink as usual is appropriate.

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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

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