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","B","C","D","E"]

Explanation

Choice A rationale
Thoracentesis may be performed to remove air from the pleural space in a client with a pneumothorax.
Choice B rationale
Obtaining arterial blood gases (ABGs) can help assess the client’s respiratory status and the severity of the pneumothorax.
Choice C rationale
A computed tomography (CT) scan of the chest can provide detailed images of the lungs and can help confirm the diagnosis of a pneumothorax.
Choice D rationale
Preparation for the insertion of a chest tube may be necessary to remove air from the pleural space and allow the lung to re-expand in a client with a pneumothorax.
Choice E rationale
Obtaining intravenous access is often necessary for administering medications and fluids.

A. Potential Condition: Bleeding, Actions to Take: Observe surgical dressing, obtain blood cultures, Parameters to Monitor: Blood pressure, Patient’s performance of lung expansion exercises. B. Potential Condition: Air leak, Actions to Take: Check the drainage system, Parameters to Monitor: Respiratory status, Chest tube drainage. C. Potential Condition: Pulmonary edema. D. Potential Condition: Pneumonia.

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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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 nurse is caring for a client who has a pneumothorax. The nurse is reviewing the client’s medical record. What prescriptions should the nurse anticipate for a client who has a pneumothorax?

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

Explanation

What condition is the patient most likely experiencing, what two actions should the nurse take to address that condition, and what two parameters should the nurse monitor to assess the patient’s progress?

Correct Answer is B

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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?