A nurse is caring for a client who is 24 hr postoperative. Which of the following interventions should the nurse take to reduce the risk of atelectasis?
Administer morphine intermittent IV bolus every 2 hr to the client.
Turn the client from side to side every 4 hr.
Provide the client with nasotracheal suctioning for 15 to 20 seconds at a time.
Instruct the client to hold the inhaled breath for 2 to 5 seconds with incentive spirometer use.
The Correct Answer is D
Choice A rationale:
Administering morphine intermittent IV bolus every 2 hours is not a suitable intervention for reducing the risk of atelectasis. While pain management is important postoperatively, morphine can depress respiratory function and increase the risk of atelectasis.
Choice B rationale:
Turning the client from side to side every 4 hours is important for preventing pressure ulcers and promoting comfort, but it is not a specific intervention for reducing the risk of atelectasis.
Choice C rationale:
Providing nasotracheal suctioning for 15 to 20 seconds at a time is not a preventive measure for atelectasis. Suctioning may be necessary for airway clearance in certain situations, but it does not address the root cause of atelectasis.
Choice D rationale:
This is the correct choice. Instructing the client to hold the inhaled breath for 2 to 5 seconds with incentive spirometer use is an effective intervention to reduce the risk of atelectasis. Incentive spirometry helps to expand the lungs and improve ventilation, preventing atelectasis after surgery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
A three-prong plug attached to the electrical cord of the client's bed is not a safety hazard. It is a standard plug type used in many electrical devices and poses no immediate danger if properly installed.
Choice B rationale:
Inserting a protective cover into an unused outlet is actually a safety measure to prevent electrical accidents. It is not a hazard but a recommended practice.
Choice C rationale:
Plugging an IV pump into an outlet near a sink is a safety hazard. Water and electricity are a dangerous combination, and any spill or leakage around the outlet could lead to electrical shock or damage to the equipment.
Choice D rationale:
Coiling and securing an electrical cord to the floor can be a potential tripping hazard, but it is not as hazardous as having an electrical device near a sink. Tripping hazards can cause falls, while the combination of water and electricity is more likely to cause serious injuries.
Correct Answer is D
Explanation
Choice A rationale:
(Potassium level) Lovastatin is a medication used to treat high cholesterol levels. While potassium levels are important to monitor for certain conditions, they are not directly related to the initiation of lovastatin therapy. Therefore, this is not the correct choice for diagnostic testing before starting the medication.
Choice B rationale:
(Hemoglobin level) Hemoglobin levels are important to assess for anemia or other blood disorders. However, they are not specifically required before starting lovastatin therapy. Therefore, this is not the correct choice for diagnostic testing before starting the medication.
Choice C rationale:
(Kidney function tests) While kidney function tests are essential for many medications to ensure proper excretion and avoid toxicity, they are not directly related to the initiation of lovastatin therapy. Therefore, this is not the correct choice for diagnostic testing before starting the medication.
Choice D rationale:
(Liver function tests) Liver function tests are crucial before starting lovastatin therapy. Lovastatin is metabolized in the liver, and it can potentially cause liver damage or abnormalities in liver enzymes. Monitoring liver function helps detect any pre-existing liver conditions and ensures the safe use of the medication. Therefore, this is the correct choice for diagnostic testing before starting the medication.
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