A nurse teaches a post-operative patient about preventing atelectasis. Which statement by the patient indicates an understanding?
“Hyperventilation will open up my alveoli, preventing atelectasis."
“It is important for me to do breathing exercises every hour to prevent atelectasis."
"Atelectasis affects only those with chronic conditions such as emphysema. I do not have emphysema therefore I will not get this condition."
“If develop atelectasis, I will need a chest tube to drain excess fluid."
The Correct Answer is B
A. Hyperventilation can lead to dizziness and lightheadedness, and it's not a recommended method for preventing atelectasis.
B. This statement indicates understanding of the importance of deep breathing exercises in preventing atelectasis.
C. This statement shows a misunderstanding of atelectasis. Anyone can develop atelectasis, especially after surgery.
D. This statement is incorrect, but it focuses on treatment rather than prevention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["100"]
Explanation
To calculate the rate at which the IV pump should be set to deliver the medication, you would use the formula:
(Total Volume in mL / Time in hours) = mL/hr.
The total volume of the IV bag is 50 mL and the time frame is 0.5 hours (since 30 minutes is half an hour). So, the calculation would be 50 mL / 0.5 hours = 100 mL/hr.
Therefore, the nurse should set the IV pump to deliver 100 mL/hr to administer 500 mg of ampicillin over 30 minutes.
Correct Answer is B
Explanation
A. Lubricating the suction catheter tip with sterile saline is generally not recommended. The catheter tip is usually not lubricated before suctioning. Instead, suctioning should be performed using a dry, sterile catheter to prevent introducing any substances into the airway that could cause irritation or infection.
B. Hyperoxygenating the patient with 100% oxygen before suctioning is a crucial step. This helps to prevent hypoxia during the suctioning procedure, as suctioning can temporarily reduce the oxygen levels in the blood. By providing 100% oxygen for 30 to 60 seconds, the nurse ensures that the patient has an adequate oxygen reserve and reduces the risk of oxygen desaturation during suctioning.
C. Performing chest physiotherapy is not a routine pre-suctioning action and is generally done as part of a separate management strategy for clearing secretions. Chest physiotherapy involves techniques such as percussion, vibration, and postural drainage to help mobilize secretions from the lungs.
D. Instilling normal saline into the airway before suctioning (known as “normal saline lavage”) is not recommended. This practice can actually cause harm, such as increasing the risk of infection, causing bronchospasm, and diluting secretions which may then become more difficult to suction.
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