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

Incentive spirometry

Increase oral fluid intake

Ambulation

Oxygen therapy

Answer and Explanation

The Correct Answer is A

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.

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Correct Answer is ["B","C","D"]

Explanation

A. Hypotension: While hypotension can occur in clients with acute respiratory failure (ARF), it is not a primary manifestation of the condition. Hypotension may arise due to other factors, such as sepsis or significant fluid loss, but is not universally present in ARF. Therefore, it is less likely to be a key finding in this context.
B. Severe dyspnea: This is a hallmark manifestation of ARF. Clients typically experience significant difficulty in breathing due to inadequate oxygenation or ventilation, leading to an urgent need for medical intervention. Monitoring for severe dyspnea is critical as it directly indicates the severity of respiratory distress.
C. Headache: Headaches can be a manifestation of acute respiratory failure, particularly due to hypoxia or hypercapnia (elevated carbon dioxide levels) affecting cerebral circulation. This symptom may arise as the body struggles to compensate for decreased oxygen levels, making it important to monitor in clients with ARF.
D. Decreased level of consciousness: This is a significant concern in ARF and can indicate worsening hypoxia or hypercapnia. Alterations in consciousness may range from confusion to unresponsiveness and require immediate evaluation and intervention, making it a critical manifestation to monitor.
E. Nausea: Although some clients may experience nausea as a secondary symptom due to anxiety or as a response to hypoxia, it is not a primary or definitive manifestation of acute respiratory failure. Therefore, while it may occur in some cases, it is not one of the key findings to consistently monitor in clients with ARF.

A. Reports routinely list the identification number of any equipment involved. B. Reports routinely include the client's hospital number. C. Reports routinely are completed within 24 hr after the incident. D. Reports routinely omit the names of witnesses to the occurrence.

Correct Answer is D

Explanation

A. Reports routinely list the identification number of any equipment involved: This practice is appropriate and helps in tracking any equipment-related issues. Including identification numbers can assist in identifying problems with specific devices or tools and does not represent a problem that needs to be reported.
B. Reports routinely include the client's hospital number: Including the client's hospital number in reports is standard practice for maintaining accurate records and ensuring proper tracking of incidents related to specific patients. This does not indicate a problem and is essential for accountability in healthcare reporting.
C. Reports routinely are completed within 24 hr after the incident: Timeliness in completing incident reports is important, and completing them within 24 hours is a best practice. This indicates a proactive approach to addressing incidents and does not represent a problem that needs to be reported to the risk manager.
D. Reports routinely omit the names of witnesses to the occurrence: This is a significant issue that should be reported to the risk manager. Witnesses can provide valuable information about the circumstances surrounding an incident, and their names should be documented for follow-up and investigation. Omitting this information could hinder the thoroughness of the incident review and the organization’s ability to address and prevent future occurrences effectively.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

A nurse is reviewing event reports submitted during the previous month. The nurse should identify which of the following as a problem that should be reported to the risk manager?

Correct Answer is D

Explanation

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