A nurse is caring for a patient at risk for atelectasis.

Which independent nursing measure should the nurse prioritize to prevent the development of atelectasis?

Ambulation.

Oxygen therapy.

Incentive spirometry.

Increase oral fluid intake.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Ambulation is a general measure that can help improve overall lung function by promoting deep breathing, coughing, and mobilization of secretions. However, it is not the primary measure to prevent atelectasis.
Choice B rationale
Oxygen therapy is used to treat hypoxia, which can be a result of atelectasis. However, it does not directly prevent the development of atelectasis.
Choice C rationale
Incentive spirometry is a first-line measure to prevent atelectasis. It encourages deep breathing, which helps keep the alveoli inflated and can prevent them from collapsing, thus preventing atelectasis.
Choice D rationale
Increasing oral fluid intake can help to thin secretions, making them easier to mobilize. However, it is not the primary measure to prevent atelectasis.

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

Explanation

Choice A rationale
A PTT of 70 seconds (control 25-40) indicates that the patient’s blood is taking longer than normal to clot, which could increase the risk of bleeding. This could be a sign of excessive anticoagulation from the Heparin infusion.
Choice B rationale
Ecchymosis at the venipuncture site could be a sign of bleeding under the skin, which could indicate that the patient is receiving too much Heparin.
Choice C rationale
Hematuria, or blood in the urine, could be a sign of bleeding in the urinary tract, which could be a side effect of Heparin therapy.
Choice D rationale
If there is an order for Coumadin 2.5 mg to start today, the healthcare provider should be notified. Coumadin and Heparin are both anticoagulants, and using them together could increase the risk of bleeding.

A. Immunosuppressive drug therapy can facilitate organ rejection. B. Immunosuppressive drug therapy can contribute to chronic rhinosinusitis. C. Chronic rhinosinusitis can damage the transplanted organ. D. All of the above.

Correct Answer is B

Explanation

Choice A rationale
While immunosuppressive drug therapy can facilitate organ rejection, it is not directly related to the development of chronic rhinosinusitis in patients who have undergone organ transplants.
Choice B rationale
Immunosuppressive drug therapy can indeed contribute to chronic rhinosinusitis. Patients who have undergone organ transplants are often on long-term immunosuppressive therapy to prevent organ rejection. This can make them more susceptible to infections, including chronic rhinosinusitis.
Choice C rationale
Chronic rhinosinusitis does not typically damage the transplanted organ. It primarily affects the sinuses and nasal passages.
Choice D rationale
All of the above is not the correct answer because Choices A and C are not accurate in the context of chronic rhinosinusitis in patients who have undergone organ transplants.

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A nurse is caring for a patient at risk for atelectasis. Which independent nursing measure should the nurse prioritize to prevent the development of atelectasis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient diagnosed with a pulmonary embolism is receiving a continuous Heparin infusion. Which findings should prompt the nurse to notify the healthcare provider?

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

Explanation

A nurse is caring for a patient who has recently been diagnosed with chronic rhinosinusitis. What should the nurse understand about chronic rhinosinusitis in patients who have undergone organ transplants?

Correct Answer is B

Explanation

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A nurse is caring for a patient at risk for atelectasis.

Which independent nursing measure should the nurse prioritize to prevent the development of atelectasis?