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:
Having the client point their chin upward to swallow is not a recommended action to reduce the risk of aspiration. In fact, this action can increase the risk of choking and aspiration, as it may cause food or liquids to enter the airway.
Choice B rationale:
Offering the client saltine crackers between meals is not a suitable action for reducing the risk of aspiration. Saltine crackers are dry and can be challenging to swallow for someone with dysphagia, potentially increasing the risk of aspiration.
Choice C rationale:
Thicken liquids before serving is the correct action to reduce the risk of aspiration in a client with dysphagia. Thickened liquids are easier to swallow and less likely to enter the airway, reducing the risk of aspiration pneumonia.
Choice D rationale:
Placing food on the affected side of the mouth does not address the risk of aspiration directly. Dysphagia may affect both sides of the mouth, and placing food on one side does not ensure safe swallowing and reduces the effectiveness of addressing the problem.

A. Increase intake of high-fiber foods. B. Chew sugarless gum. C. Moisten the mouth with lemon-glycerin swabs. D. Rinse the mouth with nystatin.

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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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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