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 B
Explanation
Choice A rationale:
A capillary refill of less than 1 second is a normal finding and indicates adequate peripheral perfusion. It is not a cause for concern in this postoperative client.
Choice B rationale:
The presence of a pulse deficit should be reported to the provider because it suggests a discrepancy between the apical and radial pulses, indicating potential cardiovascular compromise or inadequate arterial perfusion.
Choice C rationale:
A systolic blood pressure 10 points lower than before surgery can be a normal response to anesthesia or surgery and may not necessarily require immediate reporting unless accompanied by other concerning symptoms or vital sign abnormalities.
Choice D rationale:
Pulse oximetry at 96% is within the normal range for oxygen saturation and does not warrant immediate reporting. However, if the client is experiencing respiratory distress or other concerning symptoms, it should be addressed promptly.
Correct Answer is D
Explanation
Choice A rationale:
Allergy to eggs is not a contraindication for taking chondroitin with glucosamine. These supplements do not contain eggs and are generally safe for individuals with egg allergies.
Choice B rationale:
Hypotension is not directly related to the use of chondroitin with glucosamine. These supplements are not known to cause significant changes in blood pressure.
Choice C rationale:
History of hypoglycemia is not a specific concern with chondroitin and glucosamine supplements. These supplements do not significantly impact blood sugar levels in people without diabetes.
Choice D rationale:
The correct choice. The nurse should instruct the client to use chondroitin with glucosamine with caution if they are on anticoagulant therapy. Chondroitin and glucosamine may have mild anticoagulant effects, and when combined with prescribed anticoagulant medications, there is a potential risk of increased bleeding or altered blood clotting times. It is essential to monitor the client's coagulation parameters closely if they decide to use these supplements.
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