The nursing student is reviewing interventions which are part of nursing care and prevention of atelectasis. What are some of the interventions nurses can do to prevent atelectasis? (SELECT ALL THAT APPLY)

Administer antibiotics

Encourage increased oral fluid intake

Early mobilization after surgery

Frequent turning of the patient

Use of incentive spirometry

Answer and Explanation

Correct Answer : B,C,D,E

A. Administer antibiotics

Administering antibiotics is not a direct intervention for preventing atelectasis. Antibiotics are typically prescribed to treat bacterial infections, and atelectasis is more related to lung collapse or incomplete lung expansion.

B. Encourage increased oral fluid intake

Adequate hydration is important for maintaining the moisture of respiratory secretions. This helps prevent mucus from becoming thick and sticky, making it easier for the patient to cough and clear the airways.

C. Early mobilization after surgery

Early mobilization, including activities such as getting out of bed and walking, helps improve lung expansion. It promotes better ventilation and prevents areas of the lungs from collapsing, reducing the risk of atelectasis.

D. Frequent turning of the patient

Turning the patient regularly is crucial for preventing pooling of respiratory secretions in dependent areas of the lungs. By changing the patient's position, nurses can facilitate drainage and ventilation throughout the lungs, minimizing the risk of atelectasis.

E. Use of incentive spirometry

Incentive spirometry is a breathing exercise device that encourages the patient to take slow, deep breaths. This helps expand the lungs and prevents atelectasis by maintaining lung volume and promoting alveolar recruitment.

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Correct Answer is D

Explanation

A. Monitor daily weights and urine output.

Monitoring daily weights and urine output is an important aspect of managing heart failure or other cardiac conditions. However, in the context of a client with chest pain, ST elevation, and elevated cardiac enzymes (indicating a myocardial infarction), the immediate focus is on addressing the acute event and reducing myocardial oxygen demand.

B. Administer TPA to prevent further damage as a result of a clot.

Tissue plasminogen activator (TPA) is a thrombolytic medication that can be administered to dissolve blood clots in the coronary arteries during a myocardial infarction. However, the administration of TPA has a specific timeframe within which it is most effective. It is crucial to know the elapsed time since the onset of symptoms, and there are specific criteria and contraindications for its use.

C. Provide client education on medications and diet to prevent recurrence.

Client education on medications, lifestyle modifications, and dietary changes is an essential component of long-term management for preventing recurrence of cardiovascular events. However, during the acute phase of a myocardial infarction, the immediate priority is to stabilize the client and address the acute event, with education being a secondary consideration.

D. Reduce pain and myocardial oxygen demand.

During the acute phase of a myocardial infarction, reducing pain and myocardial oxygen demand is the highest priority. This is typically achieved through the administration of medications such as nitroglycerin for vasodilation and opioids for pain relief. Other interventions to optimize oxygen supply and demand, such as supplemental oxygen and reperfusion strategies, may also be considered.

A. Standard precautions B. Airborne precautions C. Contact precautions D. Droplet precautions

Correct Answer is B

Explanation

A. Standard precautions:

Standard precautions are the basic level of infection control and should be used for all patient care. These precautions include practices like hand hygiene, the use of personal protective equipment (PPE), and safe injection practices.

B. Airborne precautions:

These precautions are used to prevent the transmission of infectious agents that are spread through the air. In the case of tuberculosis (TB), which is caused by Mycobacterium tuberculosis, airborne precautions are necessary to reduce the risk of airborne transmission.

C. Contact precautions:

Contact precautions are used for patients with known or suspected infections that can be transmitted by direct or indirect contact. Examples include Clostridium difficile infection and multidrug-resistant organisms. These precautions involve the use of PPE and may include patient placement in a private room.

D. Droplet precautions:

Droplet precautions are used when a patient is known or suspected to be infected with pathogens that are transmitted by respiratory droplets. Examples include influenza and certain types of bacterial meningitis. These precautions include placing the patient in a private room and using PPE.

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The nursing student is reviewing interventions which are part of nursing care and prevention of atelectasis. What are some of the interventions nurses can do to prevent atelectasis? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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