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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Taking breaks outside in fresh air can help to clear the lungs of inhaled toxins to some extent. However, this measure alone is not sufficient to prevent inhalation exposure of job-related substances.
Choice B rationale
Consistently wearing a disposable paper mask can provide some protection against inhalable toxins. However, such masks may not be effective against all types of toxins and may not provide complete protection.
Choice C rationale
Keeping a fan blowing in the environment can help to disperse toxic substances and prevent them from becoming stagnant in the air. However, this measure alone may not be sufficient to prevent inhalation exposure, and in some cases, it could even spread the toxins more widely.
Choice D rationale
Wearing designated protective attire and devices when working with a toxic substance is the most effective measure to prevent inhalation exposure. This can include items such as respirators, which are designed to filter out specific toxins and protect the respiratory system.
Correct Answer is B
Explanation
Choice A rationale
While bleeding is a potential complication following a thoracotomy, the actions and parameters listed do not align with the care of a patient with a chest tube.
Choice B rationale
An air leak is a potential complication following a thoracotomy with chest tube insertion. The nurse should check the drainage system and monitor the patient’s respiratory status and chest tube drainage.
Choice C rationale
Pulmonary edema is a potential complication following a thoracotomy, but the actions and parameters listed do not align with the care of a patient with a chest tube.
Choice D rationale
Pneumonia is a potential complication following a thoracotomy, but the actions and parameters listed do not align with the care of a patient with a chest tube.
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