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 ["A","D","E"]
Explanation
Choice A rationale
Culturally incompetent caregivers can be a significant barrier to appropriate communication with clients. Cultural competence involves understanding and respecting the cultural differences and preferences of clients, which can greatly influence how they perceive and respond to healthcare communication.
Choice B rationale
Proper training in healthcare communication is not a barrier, but rather a facilitator of appropriate communication with clients. It equips healthcare professionals with the necessary skills and knowledge to communicate effectively with clients.
Choice C rationale
Excellent health literacy is not a barrier, but rather a facilitator of appropriate communication with clients. Clients with excellent health literacy are better able to understand and engage in healthcare communication.
Choice D rationale
Implicit bias can be a significant barrier to appropriate communication with clients. It refers to the unconscious attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner.
Choice E rationale
Lack of diversity can be a significant barrier to appropriate communication with clients. Diversity in the healthcare workforce can enhance the understanding of the cultural and social needs of diverse client populations, thereby improving communication.
Correct Answer is A
Explanation
Choice A rationale
Auscultating the lungs for the presence of breath sounds is a priority action following endotracheal intubation. This helps to confirm correct tube placement and assess for complications such as a pneumothorax.
Choice B rationale
While it is important to ensure that the pulse oximetry is greater than 95% to confirm adequate oxygenation, this is not the priority action. The nurse should first confirm correct tube placement by auscultating lung sounds.
Choice C rationale
Assessing the baseline level of consciousness is important, but it is not the priority action following endotracheal intubation.
Choice D rationale
Assessing for the presence of circumoral cyanosis can indicate hypoxia, but it is not the priority action. The nurse should first confirm correct tube placement by auscultating lung sounds.
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