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 B
Explanation
Choice A rationale
Establishing a benchmark to identify a standard of performance is a crucial step in any quality improvement process. It provides a reference point against which progress can be measured. However, it does not directly evaluate the effectiveness of the implemented measures.
Choice B rationale
Comparing the number of medication errors before and after the implementation of the measures is the most direct and effective method to evaluate the success of the changes. This method provides quantitative data that can clearly show whether the measures have led to a reduction in medication errors.
Choice C rationale
Conducting a study on the time and cost implications of implementing the change can provide valuable information about the efficiency of the measures. However, it does not directly assess their effectiveness in reducing medication errors.
Choice D rationale
Providing a questionnaire to the staff to quantify their satisfaction with the changes can help to assess the acceptance of the measures among the staff. However, staff satisfaction does not necessarily correlate with the effectiveness of the measures in reducing medication errors.
Correct Answer is B
Explanation
Choice A rationale
This response is not appropriate as it does not address the patient’s emotional state and may come across as dismissive or coercive. It is important to approach a tearful and refusing patient with empathy and understanding, acknowledging their feelings and concerns.
Choice B rationale
This response is the most appropriate as it acknowledges the patient’s emotional state and opens up a dialogue for the patient to express their worries or concerns. By asking the patient what is worrying them, the nurse shows empathy and provides an opportunity for the patient to voice their fears or concerns, which can be the first step towards resolving the issue.
Choice C rationale
This response is not appropriate as it does not address the patient’s emotional state and may come across as dismissive or coercive. It is important to approach a tearful and refusing patient with empathy and understanding, acknowledging their feelings and concerns.
Choice D rationale
This response is not appropriate as it may come across as dismissive or insensitive. It is important to approach a tearful and refusing patient with empathy and understanding, acknowledging their feelings and concerns.
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