The nurse noticed an increase in the prevalence of pressure injury among clients in the intensive care unit (ICU). The nurse documented the findings and worked with the manager to develop and implement a new policy addressing the consistent use of pressure injury risk assessment scale. Which term best describes the nurse's actions?

Advocacy.

Quality improvement.

Case Management.

Collaboration.

Answer and Explanation

The Correct Answer is B

A. Advocacy: Advocacy involves representing the interests and needs of individual patients or groups within the healthcare system. While the nurse's actions may indirectly benefit patients by improving care standards, the focus here is on systemic changes rather than individual patient representation. Advocacy often involves lobbying for resources, policy changes, or addressing ethical concerns on behalf of patients, which is not the primary goal of the actions taken in this scenario.
B. Quality improvement: This term best describes the nurse's actions as it focuses on enhancing healthcare practices and patient outcomes through systematic efforts. By identifying the increase in pressure injuries and collaborating with management to implement a new policy, the nurse is actively participating in a quality improvement initiative aimed at reducing risks and improving care protocols in the ICU. This approach reflects a commitment to continuous improvement in patient safety and care standards, aligning with best practices in healthcare.
C. Case Management: Case management primarily involves coordinating care for individual patients, ensuring they receive appropriate services, and managing their healthcare journey. While the nurse may address pressure injuries at the unit level, the actions taken are broader and not confined to individual patient care. Case management emphasizes individualized care plans and resource allocation rather than addressing systemic issues affecting a group of patients in the ICU.
D. Collaboration: Collaboration refers to working together with others, such as colleagues and management, to achieve common goals in patient care. While the nurse did collaborate with the manager to develop and implement the new policy, collaboration alone does not capture the proactive approach taken to address the increase in pressure injuries. It emphasizes teamwork but lacks the focus on systematic quality enhancement that characterizes quality improvement efforts, which aim to implement lasting changes in practices and outcomes.

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Correct Answer is A

Explanation

A. Incentive spirometry: This is the most effective independent nursing measure to prevent atelectasis. Incentive spirometry encourages deep breathing and lung expansion, which helps to keep the alveoli open and reduces the risk of collapse. It is particularly beneficial for clients at risk for atelectasis, such as those who have had surgery, are immobile, or have respiratory issues. Regular use of the incentive spirometer promotes optimal lung function and helps prevent the development of atelectasis.
B. Increase oral fluid intake: While maintaining adequate hydration is important for overall health and can help thin secretions, it is not as directly effective in preventing atelectasis as incentive spirometry. Increased fluid intake alone does not promote deep breathing or lung expansion, which are critical in preventing airway collapse.
C. Ambulation: Although ambulation is an important intervention for promoting overall mobility and respiratory function, it may not be as practical for all clients, especially those who are unable to move independently. While getting the client up and moving can help prevent atelectasis, the most immediate and effective measure remains the use of incentive spirometry, which can be performed regardless of the client’s mobility status.
D. Oxygen therapy: While oxygen therapy can help improve oxygenation in clients with respiratory issues, it does not directly prevent atelectasis. Providing supplemental oxygen does not address the need for lung expansion and deep breathing, which are essential in maintaining alveolar patency. Therefore, oxygen therapy should not be prioritized as the primary independent measure to prevent atelectasis.

A. Increased arterial oxygen B. Increased pH C. Increased carbon dioxide D. Decreased alveolar function

Correct Answer is C

Explanation

A. Increased arterial oxygen: Clients with COPD typically experience chronic hypoxemia due to alveolar destruction, airway inflammation, and mucus production, which impair gas exchange. Rather than increased oxygen levels, they often have a decreased PaO₂, requiring supplemental oxygen therapy. However, excessive oxygen administration can suppress their respiratory drive, worsening CO₂ retention.
B. Increased pH: COPD is associated with respiratory acidosis due to chronic CO₂ retention from inadequate alveolar ventilation. While the kidneys compensate by increasing bicarbonate retention, the pH usually remains low or near normal in chronic cases rather than becoming elevated. A higher pH would indicate alkalosis, which is not typical in COPD unless there is an additional metabolic disturbance.
C. Increased carbon dioxide: COPD causes airway obstruction and reduced alveolar ventilation, leading to CO₂ retention (hypercapnia). As CO₂ accumulates in the blood, it lowers the pH, resulting in respiratory acidosis. Chronic hypercapnia is a hallmark of advanced COPD, and in response, the kidneys retain bicarbonate to partially compensate, stabilizing the pH over time but leaving PaCO₂ elevated.
D. Decreased alveolar function: While COPD does lead to progressive alveolar damage and reduced gas exchange, this is a structural and functional change rather than a specific abnormality seen in arterial blood gases. The primary ABG finding in COPD is hypercapnia, which reflects inadequate ventilation and CO₂ retention rather than just decreased alveolar function alone.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client at risk for atelectasis. Which independent nursing measure should the nurse prioritize to prevent atelectasis development?

Correct Answer is A

Explanation

A nurse is reviewing arterial blood gas results for a client diagnosed with chronic obstructive pulmonary disease (COPD). The nurse should expect which abnormal finding?

Correct Answer is C

Explanation

The nurse is assigned to a quality improvement committee to decide on a quality improvement project for the unit. Which issues should the nurse discuss at the committee meeting?

A nurse is caring for a client diagnosed with pneumonia and assesses labored breathing and copious tracheobronchial secretions. What priority action should the nurse encourage with the client?

A nurse is preparing to administer potassium chloride elixir 40 mEq divided into 2 equal doses every 12 hr. Available is 6.7 mEq/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? (Select all that apply.)

A client diagnosed with a pulmonary embolism is placed on a continuous Heparin infusion. A nurse should notify the health care provider for which of the following findings?

A clinic nurse is preparing to teach student nurses about care of clients with viral pharyngitis. Which information should the nurse include in the teaching plan? Select all that apply.

A client is being treated for bacterial pharyngitis. Which of the following should a nurse recommend when promoting the client's nutrition during treatment?

A nurse is caring for a client diagnosed with adult respiratory distress syndrome (ARDS) and being treated with positive end expiratory pressure (PEEP). The nurse should understand that PEEP will benefit the client in what manner?