A nurse is collecting data on a client who has obstructive sleep apnea. Which of the following findings should the nurse expect?

A. Auscultate breath sounds at least every 2 hours.

Regularly auscultating breath sounds is important for assessing respiratory status and detecting any signs of respiratory complications such as pneumonia or atelectasis. However, it is not the priority action in this scenario compared to applying antiembolic stockings, which directly addresses the increased risk of DVT and PE associated with immobility.

B. Perform range-of-motion exercises at least two to three times daily.

Range-of-motion exercises help prevent contractures and maintain joint mobility in immobile clients. While they are important for preventing musculoskeletal complications, they are not the priority action compared to applying antiembolic stockings, which directly addresses the increased risk of DVT and PE associated with immobility.

C. Make sure the client has an intake of 2,000 to 3,000 mL of fluid per day.

Maintaining adequate hydration is important for overall health and prevention of complications such as urinary tract infections and constipation. However, it is not the priority action in this scenario compared to applying antiembolic stockings, which directly addresses the increased risk of DVT and PE associated with immobility.

D. Apply antiembolic stockings.

The priority action for the nurse to contribute to the plan of care for an immobile client is to apply antiembolic stockings. Immobility increases the risk of deep vein thrombosis (DVT) and subsequent pulmonary embolism (PE). Antiembolic stockings (also known as compression stockings or TED stockings) help prevent venous stasis and decrease the risk of blood clots forming in the lower extremities. Therefore, applying antiembolic stockings is essential in mitigating the risk of potentially life-threatening complications associated with immobility.

A. Facial flushing

Facial flushing is not typically associated with atelectasis. Instead, it may occur in conditions such as oxygen toxicity or fever.

B. Increasing dyspnea

Atelectasis is a condition characterized by the collapse or partial collapse of a portion of the lung. Common findings in a client with atelectasis include increasing dyspnea (shortness of breath) due to impaired gas exchange and reduced lung function. As the affected lung tissue collapses, ventilation and oxygenation are compromised, leading to difficulty breathing.

C. Decreasing respiratory rate

A decreasing respiratory rate is not typically observed in a client with atelectasis. Instead, respiratory rate may increase as the body attempts to compensate for the impaired gas exchange and oxygenation resulting from lung collapse.

D. Dry cough

While coughing is a common symptom of atelectasis, it is typically associated with a productive cough rather than a dry cough. A dry cough is more commonly associated with conditions such as viral respiratory infections or allergic reactions. In atelectasis, the cough may be productive as the body attempts to clear mucus or other secretions from the affected airways.